THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


LABYRINTH    PAPERS 


BY 


GEORGE  W.  MACKENZIE,  M.  D. 


PHILADELPHIA,  PA. 


THIS  COLLECTION  OF  1'Al'KKS  IS 
DEDICATKD  To  MY  FRIEND  AND 
TBACHBR, 

PROFESSOR  GUSTAV  ALEXANDER. 


tiiomedieaJ 
Library 

wv 


1113 


VORWORT. 

Es  bereitet  mir  eine  grosse  Genugthuung,  dem  vorliegenden  \Yerke 
meines  Freundes  und  langjahrigen  Schiilers  Dr.  George  \\".  Mackenzie 
einige  Worte  vorausschicken  zu  diirfen. 

Durch  die  Forschungsergebnisse  der  letzten  Jahre  hat  die  Klinik 
der  Labyrintherkrankungen  eine  vollkommene  Umgestaltung  und 
ungeahnte  Bereicherung  erfahren.  Die  modernen  Untersuchungsme- 
thoden  des  Ohrlabyrintbes  setzen  uns  instand  Erkrankungsformen  und 
Erkrankungsgrade  des  Labyrinthes  zu  diagnoszieren,  die  in  friiherer 
Zeit  \vegen  der  Geringfiigigkeit  der  Initialsymptome  oft  lange  unent- 
deckt  geblieben  sind. 

Auch  die  Bebandlung  der  Labyrintherkrankungen  hat  eine  neue 
Gestaltung  erfahren;  es  gilt  diese  sowohl  fur  die  leichteren  Formen 
nnd  die  conservative  Behandlung  als  auch  fiir  die  operative  Behand- 
lung  der  sclnveren  und  komplizierlen  Formen  der  Labyrintheiterung. 

Dr.  George  W.  Mackenzie  hat  unter  meiner  Leitung  mehrere  Jahre 
sein  ganzes  Konne-n  und  Studium  der  Frage  der  Labyrinthkrankheiten 
gewidmet.  Ich  habe  im  Laufe  dieser  Zeit  nicht  bloss  erkannt,  dass  er 
das  \\issenschaftliche  Material  vollstandig  beherrscht,  sondern  dass  er 
auch  in  vorzuglicher  \\"eise  imstande  ist,  Andere  in  die  klinische  Un- 
tcrsuchungs-  and  Behandlungs  rethoden  einzufiihren  und  zu  unter- 
richten. 

Dr.  George  \Y.  Mackenzie  scheint  daher  in  besonderer  Form  berufen 
und  vorziiglich  befahigt,  ein  Buch  iiber  die  Klinik  der  Labyrinthkrank- 
heiten zu  verfassen. 

Das  Ziel.  das  er  sich  bei  der  Abfassung  des  Buches  gesteckt  hat,  hat 
er  vollstandig  und  in  vorzuglicher  Weise  errcicht. 

Mas  Buch  \\ird  ebenso  sehr  dem  Otologen.  als  auch  dem  Chirurgen, 
Xervenarzt.  Tnternisten  und  Paediater  ein  willkommener  Behelf  sein. 

DR.  GUSTAV  ALRXAXDI.K. 

a.  o.  Professor  an  der  A'.  A'.   Wiener  Universitat 
Vorst  and  der  Ohrenabteile  d.  Algetnein 

Wein. 


CONTENTS 


PAGES. 

Introductory    Remarks    4 

Diagnosis  and  Treatment  of  Labyrinth   Suppuration    5 

Labyrinth    Suppuration — Two    Cases    13 

Labyrinth    Suppuration— Differential    Diagnosis    33 

Differentiation  of  Labyrinth  Suppuration  from  Cerebellar  Abscess    46 

Differentiation  of  Labyrinth  Suppuration  from  Affections  of  the  Eighth  Nerve  62 

Prognosis  and  Treatment  of  Labyrinth  Suppuration    77 

Physiology  and  Pathology  of  the  Non-Acoustic  or  So-Called   Static  Laby- 
rinth— Aanatomy     95 

Nystagmus    1 16 

Turning  and  After-Turning  Nystagmus    130 

Caloric    Nystagmus    150 

Galvanic    Nystagmus 161 

Urticulus  and   Sacculus   : 174 

Vertigo    !88 

Labyrinth    Fistula    .200 

Report  and  Discussion  of  Labyyrinth  Fistula    .  210 


INTRODUCTORY  REMARKS. 

At  the  request  of  many  friends  in  the  profession,  who  have  lookea 
with  favor  upon  my  writings  on  the  Labyrinth,  I  consent  to  the  publica- 
tion of  the  collection  in  this  volume. 

In  June,  1908,  when  presenting  my  first  paper  on  the  subject  of 
Labyrinth  Suppuration,  there  was  no  intention  of  writing  so  exten- 
sively upon  the  Labyrinth ;  however,  requests  for  others  came  in  such 
rapid  succession  that  it  was  not  long  before  I  realized  that  I  was  fairly 
launched  in  compiling  a  series  of  papers.  The  papers  herein  contained 
were  witten  for  various  Societies  and  Journals  between  June,  1908, 
and  February,  1911. 

Each  of  these  papers  practically  comprises  a  chapter.  The  effort 
was  to  make  each  paper  complete  in  itself  and  still  make  the  various 
papers  dove-tail  into  each  other,  and  in  the  end  to  make  the  series  com- 
plete by  covering  every  phase  of  the  subject  of  the  Labyrinth  and  its 
diseases. 

In  a  few  instances,  repetitions  appear ;  however,  where  they  have 
occurred  the  writer  had  thought  them  of  sufficient  importance  to  war- 
rant the  repetition. 

I  wish  to  take  this  opportunity  of  thanking  my  friend  and  teacher, 
Professor  Adam  Politzer,  with  whom  I  studied  and  worked  as  aspirant 
assistant  in  the  general  hospital  of  Vienna;  and  no  less  to  Professor 
Gustav  Alexander,  with  whom  I  studied  and  worked  as  aspirant  assist- 
ant in  the  Polyclinic  of  Vienna.  With  the  latter  I  spent  two  most 
profitable  years,  receiving  valuable  suggestions  and  encouragement. 


THE  DIAGNOSIS  AND  TREATMENT  OF  LABYRINTH  SUP- 
PURATION. 

OUR  knowledge  of  labyrinth  suppuration,  developed  during  the 
last  few  years,  has  revolutionized  the  science  of  otology. 
At  the  present  time  no  one  can  pretend  to  practice  otology 
who  is  not  thoroughly  familiar  with  this  subject. 
An  understanding  of  labyrinth  suppuration  presupposes : 

1.  A  knowledge  of  the  anatomy  of  the  inner  ear  and  the  relative 
positions  of  the  semicircular  canals  in  the  skull. 

2.  A   knowledge   of   the   physiology,   especially   of  the   nonacoustic 
labyrinth,    as    determined    by    Ewald,    Breuer,   Crum-Brown.    Mach, 
Kreidl.    Alexander.    Kub<>.    I'.arany.  Stein.  Krotoscheiner  and  others. 

Upon  the  more  recently  gained  knowledge  of  the  physiology  of  the 
nonacoustic  labyrinth,  exact  examination  methods  have  been  developed 
which  make  possible  an  exact  diagnosis  in  practically  every  case  of 
labyrinth  suppuration. 

The  time  allowed  will  not  permit  me  to  discuss  in  detail  the  physi- 
ology of  the  labyrinth ;  however,  for  practical  purposes,  enough  of  the 
physiology  will  be  brought  out  while  discussing  the  diagnosis  an;!  the 
methods  of  examination  used.  The  symptoms  and  signs  of  acute  laby- 
rinth suppuration  are  briefly  as  follows : 

1.  Deafness  of  sudden  onset. 

2.  Vertigo  with  nausea  and  vomiting. 

3.  Spontaneous  rotatory  nystagmus  toward  the  sound  side. 

4.  Disturbances  of  equilibrium. 

5.  Negative  caloric  reaction. 

6.  Diminished  or  negative  reaction  to  turning. 

7.  Diminished  or  negative  reaction  to  Galvanism. 

We  shall  now  discuss  separately  the  above  symptoms  and  signs  in 
the  order  given. 

i.  Deafness  of  sudden  onset. 

Deafness  is  a  constant  symptom  of  acute  labyrinth  suppuration 
which  differentiates  it  from  other  forms  of  labyrinthitis — diffuse 
serous  labyrinthitis  and  circumscribed  labyrinthitis.  In  the  suppura- 
tive  form  of  labyrinthitis  the  deafness  is  complete  and  permanent,  while 


S  TREATMENT  OF  LABYIU.\TH  SUPPURATION. 

in  the  other  forms  there  are  remains  of  hearing  ami  the  ultimate  prog- 
nosis to  hearing  is  good. 

Since  no  one  would  care  to  remove  a  labyrinth  where  there  are  re- 
mains of  hearing,  nor  on  the  other  hand  neglect  to  operate  a  suppurat- 
ing labyrinth  where  the  mortality  without  operation  is  above  70  per 
cent.,  the  determination  of  deafness  becomes  a  question  of  vital  import- 
ance to  the  patient'^  hearing  in  the  one  instance  and  to  the  patient's 
life  in  the  other. 

Prior  to  the  introduction  of  the  new,  small  (a^  fork  of  Bezold,  the 
only  errors  made  in  the  diagnosis  of  labyrinth  suppuration  arose  from 
the  uncertainty  in  the  determination  of  deafness  in  a  case  where  all 
other  signs  and  symptoms  were  positive.  At  that  time  the  best  method 
for  recognizing  onesided  deafness  was  the  2  and  3  meter  speaking- 
tube. 

I  have  examined  cases  of  unilateral  deafness  with  the  speaking  tube 
when  it  seemed  impossible  for  the  patient  to  hear  from  the  good  ear, 
which  was  completely  closed  with  a  moistened  finger,  and  yet  they  were 
able  to  repeat  whispered  words.  Experimentally  I  have  examined 
cases  where  the  labyrinth  had  been  removed,  and  the  patient  was  ap- 
parently able  to  hear  whispered  words  from  that  side  through  the 
tube.  The  only  explanation  is  that  the  sound  must  have  been  trans- 
mitted to  the  well  ear.  To  avoid  all  possibility  of  transmission  of 
sounds  to  the  well  ear,  Bezold  designed  the  new  small  (at)  fork, 
which  has  the  advantage  of  being  heard  very  distinctly  when  held 
close  to  the  ear  and  of  not  being  heard  at  all  at  a  distance  of  7  or  8 
inches  (the  width  of  the  skull  or  the  distance  necessary  to  be  traversed 
in  order  to  be  heard  by  the  other  ear).  I  have  examined  a  number  of 
cases  of  one-sided  deafness,  using  both  methods  (the  tube  and  the 
small  a,  fork)  and  the  fork  has  invariably  ^iven  more  satisfactory  re- 
sults than  the  3  meter  tube.  Beside  these  methods,  the  other  functional 
hearing  tests  (Rhine,  Schwabach,  Weber  and  the  continuous  chain 
of  forks)  will  be  an  aid  in  diagnosing  one-sided  deafness. 

2.  Vertigo  with  nausea  and  vomiting. 

In  acute  labyrinth  suppuration  the  vertigo  is  very  intense  and  in- 
variably associated  with  nausea  and  vomiting.  The  vertigo  is  most 
pronounced  at  the  onset  of  the  process  but  gradually  diminishes  after 
three  days;  however,  brief  attacks  of  vertigo  may  be  produced 
by  rapid  movements  of  the  head  for  several  weeks  afterward.  This 


LABYRIXTIl  I'.irilKS.  g 

vertigo  is  characteristic  and  known  as  vestibular  vertigo ;  it  must  be 
differentiated  from  ocular  and  central  vertigo.  Vestibular  vertigo  is 
characterized  by  certain  subjective  phenomena.  The  patient  feels  that 
the  room  and  surrounding  objects  are  moving  about  him  in  a  circle 
around  his  axis  of  vision.  The  direction  of  this  movement  in  a  case 
of  left  labyrinth  suppuration  is  the  same  as  that  made  by  the  hands  of 
a  clock,  and  when  the  eyes  are  closed  the  patient  has  the  sensation  of 
falling  to  the  right.  In  case  of  a  right  labyrinth  suppuration  the  sen- 
sations are  reversed. 

Yestibular  vert'igo  combined  with  sudden  deafness  speaks  for  some 
destructive  process  of  the  labyrinth,  and  when  found  in  the  course  of 
chronic  suppuration  of  the  middle  ear  speaks  for  acute  labyrinth  sup- 
puration. 

For  a  further  description  of  vestibular  vertigo  and  its  differentiation 
from  the  other  types,  see  Panse's  Work  on  Schwindel,  1902. 

3.  Spontaneous  rotatory  nystagmus  toward  the  sound  side. 

This  symptom  is  constantly  present,  and  like  the  vertigo  it  is  most 
pronounced  upon  the  first  day  and  gradually  diminishes  during  the  fol- 
lowing three  or  four  we?ks.  when  it  practically  ceases.  In  exceptional 
cases  it  may  be  observed  months  afterward. 

The  vestibular  nystagmus  is  due  to  the  overbalance  of  impulses  from 
the  normal  side  (Normal  Tonus}.  This  normal  tonus  can  be  better 
understood  when  we  produce  artificially  a  condition  similar  to  that 
found  in  labyrinth  destruction.  This  experiment  can  be  made  upon 
normal  people  by  applying  the  anode  to  one  side  (say  the  right  side)  ; 
this  produces  an  anelectrotonus  of  the  right  side,  suppressing  the 
normal  tonus.  At  the  same  time  the  normal  tonus  from  the  opposite 
or  left  side  pr<>< luces  an  overbalance  of  vestibular  impulses  from 
the  left  side  and  thereby  a  nystagmus  to  the  left.  Spontaneous  nystag- 
mus associated  with  labyrinth  suppuration  is  most  pronounced  when 
the  patient  looks  toward  his  well  side  (the  side  of  his  nystagmus)  ; 
however,  during  the  first  few  days  it  may  be  observed  in  all  positions 
of  the  eyeball. 

4.  Disturbances  of  equilibrium. 

These  may  be  divided  into  two  separate  forms: — the  early  and  the 
late.  The  early  is  more  marked  and  is  so  intense  as  to  amount  to  a  loss 
of  equilibrium,  which  compels  the  patient  to  seek  a  recumbent  position. 


,o  TKl-.lT.Mi-.\T  01-  LABYRINTH  SUPPURATION. 

The  tendency  ,.f  the  patient  is  to  fall  towards  the  diseased  side.  This 
tendency  is  increased  when  the  eyes  are  closed.  Falling  to  the  diseased 
side  may  be  termed  "Reaction  falling"— an  associated  phenomenon  of 
nystagmus. 

The  explanation  of  this  phenomenon  is  as  follows:  In  a  case  of 
right  labyrinth  suppuration  the  patient  has  rotatory  nystagmus  to  the 
left,  accompanied  by  the  subjective  sensation  of  falling  to  the  left. 
In  his  attempt  to  correct  this  subjective  sensation  of  falling  to  the  left, 
he  overcorrects  and  actually  falls  to  the  right  (toward  the  diseased 

side). 

The  late  form  of  disturbance  of  equilibrium  is  not  accepted  by  some 
authors,  including  Barany ;  however  I  hold  that  there  is  a  late  form, 
as  do  also  Alexander.  Kreidl.  Stein.  Krotoscheiner,  Frey  and  Ham- 
merschlag.  Recently  I  conducted  a  series  of  experiments  upon  a  num- 
ber of  cases,  of  late  one-sided  labyrinth  destruction  and  deaf-mutes 

c  "Klinische  Untersuchungen  iiber  die  labyrinthaeren  Gleichgewicht- 
nmgen  u.  s.  w."  Arch.  f.  Ohren.  Bd.  78,  1909. 

I  found  that,  without  exception,  every  case  of  late  one-sided  laby- 
rinth destruction  showed  positive  signs  of  disturbance  in  equilibrium 
by  the  following  tests:  Khomberg.  the  gait  (forward,  backward  and 
to  the  sides,  with  open  and  closed  eyes),  standing  on  one  foot,  hop- 
ping forward  and  backward  upon  one  foot,  elevation  on  the  Alexander 
Stein  goniometer  with  the  face  forward,  backward  and  to  the  two 
sides,  with  open  and  closed  eyes. 

5.  Negative  caloric  reaction. 

This  examination  method  belongs  to  Barany  (see  his  book  on  Phy- 
siologic und  I\itliolo^ic  lies  jio^cngdiigs  .Ipparat).  1908.  Before  the 
time  of  llarany,  Breuer  and  others  had  experimentally  produced 
vertigo  in  man  and  nystagmus  of  the  head  in  animals,  by  the  use  of 
cold  water  syringed  into  the  external  canal;  however,  it  remained  for 
Barany  t»  tir>t  adopt  these  reactions  for  clinical  purposes. 

The  normal  ear  syringed  with  water  colder  than  the  body  tempera- 
ture, produces  a  rotatory  nystagmus  to  the  opposite  side,  lasting  for  a 
few  minutes ;  whereas  water  warmer  than  the  body  tem- 
perature produces  the  opposite  effect — rotatory  nystagmus  to  the  same 
side.  These  caloric  reactions  are  explained  by  Barany  as  due  to  cur- 
rents set  up  in  the  endolymph  in  the  same  manner  as  all  other  cur- 


LABYRIXTH  PAPERS.  u 

rents  are  produced  in  vessels  containing  fluid,  when  the  temperature 
of  any  part  of  the  fluid  is  changed. 

One  thing  characteristic  of  the  caloric  reaction,  worth  mentioning 
here,  is  that  the  nystagmus  may  be  changed  in  character  and  direction 
by  changes  in  position  of  the  head.  As  an  illustration :  If  we  syringe 
the  right  ear  with  cold  water  with  the  head  in  an  upright  position  a 
rotatory  nystagmus  to  the  left  is  produced ;  now  if  we  turn  the  head 
90°  to  the  left  so  that  the  head  rests  upon  the  left  shoulder,  the 
rotatory  nystagmus  to  the  left  changes  to  a  horizontal  nystagmus  to  the 
right. 

The  caloric  test  is  the  most  certain  qualitative  test  of  the  nonacoustic 
labyrinth,  and  when  negative  speaks  for  destruction  of  function  in  the 
semicircular  canals  (a  most  valuable  diagnostic  sign  of  labyrinth  sup- 
puration). This  method  of  examination  is  inapplicable  in  cases  of  ob- 
struction of  the  external  canal  (atresia,  stricture,  severe  otitis  ex- 
terna,  furunculosus  and  large  polyps),  also  in  very  acute  inflammation 
with  small  perforations.  In  such  cases  it  is  well  to  be  able  to  rely 
upon  other  methods  of  examination  yet  to  be  described. 

6.  Diminished  or  negative  reaction  to  turning. 

This  is  an  important  sign  found  in  labyrinth  suppuration.  The  turn- 
ing test  is  made  with  the  patient  sitting  on  a  revolving  stool,  fitted  with 
a  handle  which  the  examiner  uses  to  turn  the  patient. 

Normally,  turning  to  the  right  with  the  head  in  the  upright  position 
produces  a  horizontal  nystagmus  to  the  right  during  turning  and  a 
horizontal  nystagmus  to  the  left  upon  stopping.  If  the  head  is  inclined 
forward  90°  a  rotatory  nystagmus  to  the  right  is  produced  during 
turning  and  to  the  left  after  turning.  This  latter  nystagmus  is  called 
the  "After  turning"  or  "After  nystagmus." 

If  the  head  is  inclined  to  the  right  90°  (that  is  the  right  side  of  the 
face  upon  the  right  shoulder)  a  vertical  nystagmus  upwards  is  pro- 
duced during  turning  to  the  right  and  vertically  downwards  after 
turning. 

If  the  position  of  the  head  is  changed  180°  to  any  of  the  above  posi- 
tions, the  opposite  nystagmi  are  produced.  Inclination  of  the  head  45° 
in  either  of  the  lateral  positions  produces  oblique  nystagmi.  In  short, 
it  is  possible  to  produce  nystagmus  in  any  desired  direction  by  change 
of  position  of  the  head.  It  is  even  possible  to  produce  mixed  forms ; 


12  TREATMENT  OP  LABYRINTH  SCI'PL'KATIOX. 

as  an  illustration:  Upon  bending  the  head  backward  45°  we  get  a 
horizontal  nystagmus  to  one  side  combined  with  a  rotatory  nystagmus 
to  the  opposite  side.  For  practical  purposes,  however  we  may  limit 
our  examinations  to  the  horizontal  and  rotatory  nystagmi. 

Normally  the  horizontal  "after-nystagmus"  lasts  from  15  to  30 
seconds  after  10  turnings ;  the  rotatory  a  trifle  longer :  however,  the 
duration  of  the  horizontal  after-nystagmus  may  be  prolonged  by  the 
use  of  opaque  spectacles  or  by  having  the  patient  look  at  a  distant  ob- 
ject to  avoid  convergence  of  the  eyes  which  inhibits  the  nystagmus. 

If,  in  a  case  of  suspected  right  sided  labyrinth  suppuration  the  re- 
action to  the  right  side  is  negative  or  of  but  a  few  seconds  duration, 
while  the  reaction  to  the  left  side  is  15  seconds  or  more,  then  the  diag- 
nosis is  assured. 

7.  Diminished  or  negative  reaction  to  galvanism. 

Prior  to  six  months  ago  the  galvanic  reaction  of  the  labyrinth  was 
a  much  neglected  subject,  owing  to  the  crude  and  inaccurate  methods 
vused.  Since  then  I  devised  a  simple  method  of  examination  (Klin- 
ische  Studit-n  uber  die  Functions  prufung  des  Labyrinthes  mittlest  de^ 
galvanischen  Stromes.  Archiv.  fur  Ohrenheilkunde.  Bd.  77 — 1908), 
the  examination  is  made  with  one  pole  in  the  hand  and  the 
second  pole  applied  to  the  region  of  the  ear,  just  in  front  of  and  above 
the  tragus.  The  current  is  applied,  gradually  increasing  until  nysla^- 
mus  is  apparent  and  the  strength  of  current  necessary  to  produce  the 
reaction  noted  in  milliamperes.  A  record  is  made  of  the  kathodal  and 
anodal  reaction  of  the  two  sides. 

Normally  4  ma.  with  kathode  to  the  right  ear  produces  rotatory 
nystagmus  to  the  right,  and  4  ma.  anode  to  the  right  ear  produces 
rotatory  nystagmus  to  the  left,  and  vice  versa  for  the  left  ear. 

In  a  case  of  right  sided  labyrinth  suppuration  the  kathode  to  the 
right  ear  fails  to  produce  a  reaction  with  as  much  as  8  ma.  or  more, 
while  kathode  to  the  left  ear  produces  a  reaction  with  less  than  4  ma. 
In  a  similar  nianm-r  we  obtain  the  reactions  with  the  anode  (the  right 
ear  does  not  react). 

In  a  similar  manner  we  obtain  the  reaction  with  the  anode  (the  right 
ear  does  not  react). 

A  further  examination  of  the  opening  and  closing  nystagmus  of  the 
two  sides  is  as  follows : 


LABYRINTH  PAPERS.  13 

Right  labyrinth  acutely  destroyed. 
*R.  Ear— K.  O.  X.  >  K.  C.  N. 

A.  C.  N.  >  A.  O.  N. 
L.  Ear— K.  C.  N.  >  K.  O.  N. 

A.  O.  N.  >  A.  C.  N. 

The  above  reactions  apply  to  the  earlier  stages  of  acute  labyrinth 
suppuration ;  however,  after  secondary  degeneration  of  the  nerve  has 
taken  place  it  is  impossible  to  obtain  either  kathodal  or  anodal  reactions 
from  the  diseased  side. 

In  closing  the  subject  of  diagnosis,  I  wish  to  emphasize  that  sudden 
deafness  in  the  course  of  middle  ear  suppuration,  together  with  spon- 
taneous rotatory  nystagmus  to  the  sound  side  and  vertigo,  speak  for 
labyrinth  suppuration ;  but  in  addition,  when  the  nonacoustic  labyrinth 
of  that  side  is  nonreactive  to  the  above  mentioned  tests,  then  the  diag- 
nosis of  labyrinth  suppuration  is  certain. 

TREATMENT. 

There  is  but  one  treatment  for  acute  labyrinth  suppuration ;  that  is 
immediate  radical  operation  combined  with  vhe  labyrinth  operation, 
for  the  following  reasons  : 

i. — Labyrinth  suppuration  is  frequently  associated  with  intracranial 
complications;  the  more  frequent  of  which  complications  are  menin- 
gitis and  cerebellar  abscess. 

2. — The  prognosis  in  nonoperated  cases  is  bad ;  the  mortality  being 
over  70  per  cent,  whereas  the  mortality  from  labyrinth  operation  is 
less  than  8  per  cent.  \Yhile  the  mortality  is  high  in  the  nonoperative 
cases,  it  is  still  higher  in  those  cases  where  the  radical  operation  is  done 
and  the  labyrinth  operation  left  undone  than  in  those  cases  where  no 
operation  is  done  at  all.  In  other  words  it  is  safer  to  leave  a  case  of 
labyrinth  suppuration  to  itself  than  to  attempt  any  half  way  measures. 

OPERATION. 

The  operation  consists,  first,  in  the  regular  Kuester-Bergmann  radi- 
cal; second,  the  laying  free  of  the  dura  of  the  middle  and  posterior 
fossae  and  removing  the  bridge  of  bone  between  them ;  third,  removal 


*K.  O.  N.  =  Kathodal  Opening  Nystagmus;  K.  C.  N.  =  Kathodal  Closing  Nys- 
tagmus; A.  O.  N.  =  Anode  Opening  Nystagmus;  A.  C.  N.  =  Anode  Closing  Nys- 
tagmus; ^>  =  greater  than. 


I4  TRI-.lTMl-XT  OF   L.\HYR1\TI1  SUPPURATION. 

of  the  semicircular  canals  from  behind  and  the  free  opening  of  the 
cochlea  and  vestibule  in  front,  allowing  the  facial  nerve  to  remain  in- 
tact. 

The  dura  is  exposed  for  a  double  purpose : — 
i. — To  allow  room  for  the  labyrinth  operation  and 
2. — To  permit  inspection  of  the  membranes,  since  many  of  these 
cases  have  more  or  less  meningitis  as  a  complication. 

The  question  of  labyrinth  suppuration  is  a  very  important  one  and 
almost  too  large  for  a  single  paper ;  my  effort  has  been  to  cover  as 
briefly  as  possible  the  entire  subject. 


LABYRINTH  SUPPURATION— TWO  CASES.* 

THIS  paper  is  intended  to  supplement  a  former  paper  upon 
"Diagnosis  and  Treatment  of  Labyrinth  Suppuration." 
The  object  is  to  report  in  full  and  discuss  two  cases  of  typi- 
cal labyrinth  suppuration.     It  is  the  opinion  of  the  writer  that  a  thor- 
( .ugh  report  of  one  or  at  most  two  cases  is  worth  more  practically  than 
a  less  thorough  report  of  a  greater  number  of  cases. 

The  two  cases  here  reported  are  selected  from  a  series  of  twenty 
as  the  more  classical  cases  of  labyrinth  suppuration.  Copied  from 
the  records  the  cases  are  as  follows : 

Case  I. — Franz  G.,  24  yrs.  old,  laborer. 

Diagnosis. — Otitis  Media  Suppurativa  Chronica  Sinistra  et  Choles- 
teatoma  et  Labyrinthitis  Suppurativa  Acuta  et  Meningo-Enceph- 
alitis  Serosa. 

History. — Left  ear  has  been  discharging  since  early  childhood.  The 
patient  could  not  recall  exactly  when  or  how  it  began.  The  discharge 
has  not  been  continuous,  often  ceasing  for  months  at  a  time.  He  had 
never  been  treated  for  the  ear  until  ten  days  before  admission.  The 
left  ear  has  been  discharging  continuously  for  the  last  seven  weeks; 
during  this  time  the  patient  complained  of  greater  impairment  of  hear- 
ing in  that  ear  and  diffused  headache,  slight  stiffness  in  the  back  of 
the  neck  and  great  weakness.  Prior  to  this  (seven  weeks  ago)  the 
patient  had  never  had  vertigo,  but  at  that  time  was  taken  with  a  very  se- 
vere attack,  which  lasted  several  days.  With  the  vertigo,  he  had  the 
sensation  as  though  he  was  being  turned  and  complained  of  darkness 
before  hi>  eyes,  he  also  vomited  repeatedly  with  great  nausea  and  he  was 
compelled  to  lie  down,  which  gave  him  slight  relief.  Upon  questioning 
he  had  had  no  chill,  and  in  his  own  words  said  he  had  had  little  or  no 
fever.  The  patient  came  on  account  of  discharge  from  and  impairment 
of  hearing  in  the  left  ear,  intense  headache,  stiffness  in  the  back  of  his 
neck  and  prostration. 


*The  tuo  cases  here  reported  are  taken  from  Prof.  Alexander's  clinic,  of 
Vienna,  with  his  permission.  The  examinations  and  records  were  made  by  the 
author  when  acting  as  Aspirant  Assistant  to  Professor  Alexander,  but  operated 
l.v  him. 


i6  L.lBYh'IXTII  SUPPURATION— TWO  CASES. 

Present  Condition. — Patient  well  nourished  and  muscular,  sallow 
Complexion  and  his  facial  expression  suggests  pain  and  apathy. 

Otoscopic  Examination — Left  Ear. — Moderate  amount  of  thick, 
grayish  yellow,  very  fetid,  purulent  secretion  in  the  external  canal. 
Slight  bulging  of  the  superior  wall  of  the  canal;  a  mass  of  polyps 
about  half  the  size  of  a  pea  hanging  down  from  the  attic-antrum 
region,  which  obstructed  the  view  of  the  tympanic  cavity,  but  it  did 
not  interfere  with  the  introduction  of  the  Hartmann  canula  for  the 
purpose  of  washing  out  its  contents,  The  mastoid  process  slightly 
sensitive  t<>  pressure.  The  entire  left  side  of  the  head  is  more  sensitive 
tn  pressure  and  percussion  than  the  right  side. 

Right  Ear. — Membrane  slightly  cloudy,  otherwise  normal. 

Microscopic  Examination  of  the  more  solid  particles  of  the  secretion 
obtained  by  syringing  out  the  tympanic  cavity  of  the  left  ear  shows 
normal  epidermis  cells,  epidermis  cells  in  stages  of  degeneration,  pus 
cells,  fat  crystals,  cholestcarin  crystals,  active  cocci  and  bacilli  and 
debris. 

Ophthalmoscopic  Examination  showed  marked  choking  of  both  discs 
(3  diopters). 

Functional  Examination. 


Righ 
,ir     B< 

S 

t 

>ne       12  M.  -f 

12  M.    + 
12  M.   -f 

Right 
Normal, 

+     •     • 

Conversation  voice, 
Whisper  voice, 
Acoumeter, 

.    \}/2  meters.       A 
Ad  conchum. 
Ad  conchum. 

Left 
ir     Be 

>lir 

*•            M-   i 

.    Very  short. 

.     .    Schwabach,    . 
.     .     .    Rhine" 

Normal, 

Normal, 
Normal, 

...    c,,   .   . 

...      a,, 

Not  heard. 
.     Not  heard. 

+     • 

.     Watch  on  bone, 

.     .     .      

SPONTANEOUS  NYSTAGMUS. 


Marked  rotatory  nystagmus  to 
the  right  when  looking  to  the 
right. 

Vrrv  -light  rotatory  n  v^tai'.inti- 
tothe  right  when  looking -traight 


Slight  horizontal  ny>tagmus  to 
the  left  when  looking  to  the  left. 


LABYRINTH  PAPERS.  17 


DISTURBANCE   OF  EQUILIBRIUM. 

Rhomberg  positive.  Hopping  very  uncertain  and  patient  falls. 
Gait  forward  and  backward  with  closed  eyes  very  broad,  uncertain 
and  slow. 

GONIOMETER. 

Eyes  Open.  Eyes  Closed. 

26  degrees,  .  .  .  Face  forward,      ...  20  degree^. 

30  degrees,  .  .  .  Face  backward,  .         .  22  degrees. 

30  degrees,  .  .  .  Face  to  right  side,       .         .  15  degrees. 

30  degrees,  .  .  .  Face  to  left  side,          .         .  15  degrees. 

CALORIC  NYSTAGMUS. 

After  three  minutes'  syringing  of  left 
ear  with  cold  water  the  character  of  the 
spontaneous  nystagmus  was  not  changed 
(negative  reaction). 

Horizontal  after-nvstagmus  to  1  (  Horizontal  after-nystagmus  to 

lAifWD.TrTBia 

right,  1 8  seconds.  AFTER-IURN-   |       left,  9  seconds. 

Rotatory   after-nystagmus    to   ,'  ]   Rotatory  after-nystagmus    to 

right,  15  seconds.  left,  7  seconds. 

Kathode,  3  ma.  nystagmus  to  1        G\LV\NTIC        ^  Kathode,  7  ma.,  no  reaction. 

right  increased.  I     NYSTAGMUS      ^   Anode,  3   ma.,   rotatory   nys- 

Anode,  7  ma.,  no  reaction.  stagmus  to  right  increased. 

Negative,       .        COMPRESSION  AND  ASPIRATION  NYSTAGMUS,       .        Negative. 

THREE-METER  HEARING  TUBE.  {  Conversation  voice,  50  per  cent,  failures. 

I  Whisper  voice,  all  failures. 

Patient's  temperature  was  37°  C.,  pulse  68. 

Operation  by  Prof.  Gr.  Alexander. — Typical  retro-auricular  incision 
through  soft  tissues  to  bone.  Laying  free  of  the  mastoid.  Chiseling 
open  the  mastoid  and  antrum.  The  bone  was  sclerotic.  The  antrum 
and  tympanic  cavities  were  found  rilled  with  cholesteatoma  masses, 
which  were  curetted  out,  together  with  many  granulations.  The  radical 
operation  after  Kuester-Bergmann  was  carried  out.  Inspection  of  the 
horizontal  semicircular  canal  showed  a  dirty,  gray  colored  eroded  area 
and  a  fistula  (2  mm.  broad  and  5  mm.  long).  Two  parallel  horizontal 
incisions  through  the  skin  and  soft  tissues  were  made  backward,  4  cm. 
long,  from  the  upper  and  lower  ends  of  the  first  incision.  The  mastoid 
process  was  totally  removed  and  the  posterior  and  middle  skull  fossae 
freely  exposed.  Inspection  of  the  sinus  showed  it  to  be  normal.  There 
2 


,8  LAHYRIXTH  SUPPURATION— TWO  CASES. 

were  no  granulations  on  the  dura.  The  semicircular  canals  were  then 
removed  from  behind,  the  horizontal  being  left  till  last.  Opening  of  the 
vestibule  and  accidentally  the  facial  nerve  was  slightly  exposed.  The 
facial  canal  was  eroded  in  part  by  the  cholesteatoma.  Chiseling  open 
of  the  promontory.  The  entire  labyrinth  was  softened.  By  incising 
the  dura  of  the  posterior  and  middle  fossa  a  small  amount  of  cloudy 
cerebrospinal  fluid  flowed  out  and  the  brain  substance  prolapsed 
through  the  incision.  The  dural  incision  was  dressed  with  a  quantity 
of  indoform  gauze.  Plastic  was  made  after  Pause.  Wound  dressing 
and  bandage. 

Lumbar  puncture  was  then  made,  15  cc.  of  cloudy  fluid  collected  iri 
three  separate  test  tubes  for  further  examination.  The  flow  of  fluid 
came  with  force  indicating  great  pressure. 

Immediately  after  the  operation  a  slight  facial  paralysis  in  all 
branches  of  the  7th  nerve  was  observed.  The  character  of  the  nystag- 
mus remained  unchanged.  The  temperature  8  P.  M.  of  the  same  day 
was  39  C.  Patient  was  restless  and  an  injection  of  morphine  was 
given. 

First  day  after  operation  there  was  no  change  in  the  facial  paralysis. 
Less  headache  than  before  the  operation.  Temperature  37°  C,  pulse 
68.  Patient  was  able  to  sit  up  in  bed  and  said  he  felt  good. 

Second  day  after  operation,  no  headache,  no  vertigo,  nystagmus  un- 
changed. Patient  had  slept  well  and  restful.  Temperature  37.3°  C 
and  pulse  68. 

Third  day  after  operation,  the  patient  felt  generally  good  except 
for  a  slight  frontal  headache.  Temperature  36.6°  C,  pulse  74.  A 
purgative  was  given. 

Fourth  day. — First  change  of  outer  dressings. 

Fifth  day. — Patient  slightly  weak,  otherwise  the  patient  said  he 
felt  perfectly  well. 

Sixth  day. — Second  change  of  dressings.  Wound  showed  healthy 
granulations. 

For  the  next  seven  days  the  patient  walked  about  the  room  at  will 
and  was  free  from  symptoms. 

n  the  fourteenth  day  after  the  operation  a  thorough  functional 
examination  of  the  nonacoustic  labyrinth  was  made  and  the   results 
found  to  correspond  exactly  with  the  findings  before  the  opera- 
tion. 


L.tKYRIXTH   PAl'liRS.  19 

Fifteenth  day,  under  local  anesthesia  with  Schleich's  solution,  the 
retro-auricular  wound  was  closed  with  secondary  sutures  excepting 
the  lo\ver  tip  for  il/2  cm.  Patient  was  discharged  from  the  hospital 
with  the  advice  to  report  every  other  day  for  further  treatment. 

One  month  after  the  operation  the  patient  felt  entirely  well  and  had 
gained  in  weight.  Retro-auricular  wound  entirely  healed.  Facial 
paralysis  unchanged. 

Six  weeks  after  the  operation  the  patient  was  free  from  all  symp- 
toms. Slight  return  of  function  of  the  Jth  nerve.  The  nonacoustic 
labyrinth  examination  gave  same  results  as  before.  There  was  still 
^ome  slight  mucoid  secretion  in  the  bottom  of  the  canal.  The  patient 
was  discharged  and  sent  to  his  home,  to  be  further  treated  by  the  local 
physician. 

Case  II. — Antonia  K.,  40  yrs.  old,  housekeeper. 

Diagnosis. — Otitis  Media  Suppurativa  Sinistra  et  Labyrinthitis  Sup- 
purativa  et  Meningitis  Serosa. 

History. — As  a  child  began  with  discharge  from  the  left  ear,  ex- 
actly as  to  how  it  began  could  not  be  ascertained.  The  discharge  was 
intermittent,  the  longest  intermission  being  five  years.  Between  the 
•second  and  twelfth  years  of  age  the  patient  suffered  from  tubercular 
glands  in  the  neck  and  axilla.  Also  had  repeated  attacks  of  inflamma- 
tion of  the  eyes  (which  proved  to  be  keratitis  eczematosa).  Fifteen 
years  ago  the  patient  was  operated  for  a  left  sided  retro-auricular  ab- 
scess ("Wild's  incision),  after  which  the  discharge  ceased  for  five 
years.  Six  weeks  before  admisison  to  the  hospital  the  patient  had  a 
heavy  attack  of  vertigo,  which  lasted  four  or  five  days,  during  which 
time  she  vomited  almost  continuously  and  suffered  greatly  from  nausea. 
She  suffered  greatly  from  thirst  and  thought  she  had  fever,  but  every- 
thing she  drank  was  vomited  almost  immediately.  The  patient  was 
obliged  to  remain  quietly  in  bed  and  every  movement  aggravated  the 
vertigo.  With  the  vertigo  the  patient  complained  of  the  sensation  of 
the  room  and  everything  in  it  turning  about  her.  Since  then  the 
vertigo  has  been  gradually  diminishing.  Two  weeks  after  this  attack 
she  went  out  of  doors  for  the  first  time,  had  a  slight  chill  and  when 
she  returned  to  the  house  she  noticed  that  her  face  was  crooked  (facial 
palsy).  Upon  admission  the  patient  complained  of  discharge  and  pains 
in  left  ear,  impairment  of  hearing,  slight  vertigo  when  making  quick 
movements,  frontal  headache — especially  on  the  left  side — and  be- 
•canse  of  this  last  symptom  the  patient  sought  the  hospital. 


20 


LAHYRi\Tii  sL'rri'RATio\—Tii'o  CASES. 


Present  Condition. — Rather  stout  and  well  nourished  woman.  Scars 
in  the  neck  from  previous  glandular  involvement.  Both  eyes  showed 
maculae  corneae,  but  the  fundi  were  negative. 

Otoscopic  Examination: 

Left  Ear. — Moderate  amount  of  brown,  very  fetid,  purulent  secre- 
tion, external  canal  slightly  narrowed.  Large  polyps  hanging  down 
from  the  attic-antrum  region  which  make  it  impossible  to  see  the 
tympanitic  cavity.  The  mastoid  process  is  slightly  sensitive  to  press- 
ure, the  periosteum  thickened  and  adherent  to  the  bone.  There  is 
an  old,  one  cm.  long,  vertical  scar  behind  the  left  auricle  representing 
the  Wild's  incision  which  had  been  performed  several  years  before. 

Right  Ear  normal. 

Microscopic  Examination  of  secretion  from  left  ear  showed  a  few 
normal  and  degenerated  epidermis  cells,  many  pus  cells,  movable  cocci 
and  bacilli,  a  few  fat  crystals  and  debris;  but  no  cholesterin  crystals. 

Functional  Examination. 


Right 
dr     Bone       I2  M-  4 
12  M.  -f- 

12  M.  + 

Conversation  voice, 
Whispered  voice,    . 
Acoumeter,    .     . 

2  meters.        \ 
Ad  conchum. 
Ad  conchum. 

Left 
ir     Bone 

Right 
Normal, 
+      •     • 

-    Weber. 
Schwabach, 
Rhine, 

Very  short. 

Normal, 
Normal, 
Normal, 

...      CT.    .     - 

...     itl 
c», 

Not  heard. 
Not  heard. 
Very  short. 

,/•'      +  •  • 

Watch  on  bone, 

.     .     .     

SPONTANEOUvS  NYSTAGMUS. 


Marked  rotatory  nystagmus  to 
the  right  when  looking  to  the 
right. 

Slight  rotatory  nystagmu-.  to 
the  right  with  opaque  glasses 
when  looking  straight  ahead. 


Slightly  rotatory  combined 
with  horizontal  nystagmus  to  the 
left  when  looking  to  the  left. 


DISTURBANCE  OF  EQUILIBRIUM. 

Rhomberg  positive  but  slight.  Gait  forward  and  backward  with 
closed  eyes  somewhat  broad  and  very  uncertain.  Patient  tends  to  fall 
laterally,  l>ut  not  to  either  side  particularly.  Hopping  impossible. 


LABYRINTH  PAPERS.  21 

GONIOMETER. 

Eyes  Open.  Eyes  Closed. 

24  degrees,       .         .         .       Face  forward,        ...  7  degrees. 

22  degrees,       .         .         .       Face  backward,    ...  7  degrees. 

23  degrees,       .         .         .       Face  to  right  side,         .         .  3^2  degrees. 
23  degrees,       .         .         .       Face  to  left  side,           .         .  3  degrees. 

CALORIC   NYSTAGMUS.  Negative. 

Horizontal after-nystaginus  to  1    \FTER  TURN*     ^  Horizontal  after-nystagmus  to 
right,  30  seconds.  I   "IXG  NvSTM."_  left,  9  seconds. 


Rotatory   after-nystagmus    to 


Mrs. 


Rotatory   after-nystagmus    to 


right,  14  seconds.  [      left,  3  seconds. 

Kathode,  2  ma.,  nystagmus  to  1  f  Kathode,    12   ma.,  nystagmus 

right  increased.                          !  GALVANIC               to  ieft. 

Anode,  12  ma.,  nystagmus  to   i  NYSTAGMUS.      j  Anode,  7   ma.,  nystagmus  to 

left.                                               j  [    -  ight. 

COMPRESSION  AND  ASPIRATION  NYSTAGMUS.       Negative 

THREE-METER  HEARING  TUBE.   {  Conversation  voice,  70  per  cent,  failures. 

I  Whispered  voice,  all  failures. 

Operation  by  Prof.  G.  Alexander. — Typical  6  cm.  long  retro-auricular 
incision  to  the  bone.  Exposure  of  the  mastoid  in  front  of  and  behind 
the  incision.  Separation  of  the  membranous  canal  from  the  posterior, 
superior  and  inferior  bony  canal.  Opening  of  the  mastoid  and  antrum. 
I'pon  opening  the  antrum  pus  flowed  freely.  Removal  of  the  posterior 
bony  canal  with  bone  forceps,  carrying  out  of  the  radical  operation  after 
Kuester-Bergmann.  The  middle  ear  spaces  were  thoroughly  curetted 
of  granulations  and  pus.  Curettement  of  the  Eustachian  tube.  Laying 
free  the  dura  of  the  posterior  and  middle  fossae  and  the  sinus  wall.  A 
granulation  the  size  of  a  pea  was  found  on  the  sinus  wall.  A  fistula 
was  uncovered,  which  led  to  the  lower  part  of  the  superior  semicir- 
cular canal  from  behind,  opening  of  vestibule,  opening  of  the  promon- 
tory in  front  of  the  facial  canal  so  that  a  bent  probe  passed  through 
from  behind  the  facial  canal  could  be  seen  anteriorly.  Clear  liquid 
oozed  through  the  anterior  opening.  Free  incision  of  the  dura  of 
both  fossae  through  which  edematous  brain  substance  prolapsed. 
Plastic  after  Panse.  Abundant  dressings  of  iodoform  gauze  were 
applied  over  the  dural  incisions,  over,  this  sterile  gauze  and  bandage. 

Several  attempts  at  lumbar  puncture  were  unsuccessful,  owing 
probably  to  excessive  amount  of  adipose  tissue  in  this  region. 

Evening  of  the  same  day  the  patient  complained  of  some  headache, 


i2  LABYRINTH  SITI'I' RATIOS— TWO  CASES. 

slight  verti-o  and  had  v unite  1  two  «>r  three  times.    Temperature  36.8°" 
C,  pulse  100. 

First  day  after  the  operation  the  patient  complained  of  headache, 
partial  facial  paralysis  of  all  branches,  slight  evidence  of  amnestic 
aphasia  and  patient  also  complained  of  being  confused. 

Second  day :  Headache  same  as  yesterday ;  patient  had  ceased 
vomiting.  Writing  test  showed  that  she  omitted  letters  in  words  and 
she  complained  of  being  forgetful.  Examination  of  fundi  again  nega- 
tive. Outer  bandage  was  slightly  loosened. 

Third  day:  Patient  still  complained  of  headache  and  could  not 
sleep.  Dressings  were  changed,  showing  a  moderate  amount  of  fetid 
secretion. 

Fourth  day:  Headache  is  less,  facial  paralysis  less.  Eye  grounds 
again  examined  and  found  negative.  Patient  felt  fairly  well. 

Fifth  day :  Headache  and  paralysis  better.  Temperature  and  pulse 
normal.  Second  change  of  dressings  and  wound  showed  normal  re- 
action. 

Seventh  day:  Third  dressing;  patient  felt  so  well  that  she  was  al- 
lowed to  leave  the  hospital  to  report  every  other  day  for  further 
treatment. 

.  End  of  fourth  week.  Patient  felt  well,  was  doing  her  regular 
housework.  At  this  time  a  thorough  functional  examination  was 
made  which  gave  the  same  results  as  before  the  operation  (see  above). 

End  of  two  months  the  patient  was  discharged  cured. 


DISCUSSION  OF  THE  CASES. 


The  taking  of  the  history  is  very  important,  especially  in  cases  of 
labyrinth  suppuration.  In  taking  the  history  I  have  adopted  a  plan 
first  suggested  by  Alexander,  i.  e., 

i. — When  did  the  suppuration  of  the  middle  ear  begin? 

2. — How  did  it  begin?  Suddenly,  with  pain,  with  fever,  how  long 
did  these  acute  symptoms  last  before  the  discharge  began  or  did  it 
begin  gradually  without  acute  symptoms? 

3- — Has  the  discharge  been  continuous  or  periodic? 

4- — Has  the  ear  been  treated  ? 

5-— Of  what  does  the  patient  complain?  Discharge,  impairment  of 
hearing,  subjective  noises,  vertigo  and  its  character,  fever,  headache, 
and  questioning  for  further  symptoms  according  to  what  may  have  sug- 
gested itself  up  t<>  this  time.  ' 

6. — Finally  a  very  brief  summary  of  symptoms  most  complained  of 
by  the  patient.  This  can  be  best  accomplished  by  putting  to  the  pa- 
tient the  question — for  what  do  you  come  ? 


LABYRIXTH  PAPERS.  23 

Observing  the  histories  of  the  cases  reported  the  reader  will  notice 
that  this  method  of  history  taking  has  been  adhered  to. 
\Ye  shall  now  discuss  the  histories  of  these  cases. 

(a)  Both  cases  began  in  early  childhood;  which  shows  that  they 
were  chronic  suppurations  of  the  middle  ear. 

(b)  The  character  of  the  onset  was  not  ascertainable,  since  the  pa- 
tients could  not  recall  it,  and  no  known  cause  in  either  case. 

(c)  The  discharge  was  periodic  in  both  cases.     This  should  prove 
to  us  the  importance  of  keeping  under  observation  all  cases  of  ap- 
parently healed  chronic  middle  ear  suppuration  for  a  long  time  after 
cessation  of  discharges  from  the  ear;  furthermore,  the  verbal  report 
of  the  patient  "that  he  has  no  further  discharge  from  the  ear"  should 
not  be  accepted,  since  in  many  cases  the  discharge  may  be  so  slight  as 
to  escape  the  notice  of  the  patient. 

(d)  In  both  cases  the  treatment  had  been  more  or  less  neglected.   In 
one  case  there  had  been  no  treatment  until  ten  days  before  admission  to 
the  hospital.    In  the  other  case  only  partial  and  improper  treatment,  in- 
cluding a  Wild's  incision  performed  several  years  before ; — a  treatment 
long  abandoned  and  condemned  by  the  best  operators. 

(e)  Both  complained  of  the  following  symptoms:  Otorrhoea,  mark- 
'ecl  impairment  of  hearing.*  vertigo,  slight  fever  (?)  and  headache. 

Neither  case  complained  of  subjective  noises.  Relative  to  this 
symptom :  I  have  never  found  subjective  noises  in  a  case  of  labyrinth 
suppuration — as  some  of  the  American  writers  have  claimed ;  however, 
subjective  noises  may  be  present  occasionally  just  before  the  onset,  but 
never  after  the  actual  development  of  the  labyrinth  suppuration,  and 
indeed  there  seems  to  be  no  logical  reason  why  there  should  be  sub- 
jective noises  in  a  case  of  suppurative  panotitis  any  more  than  there 
should  be  subjective  sensations  of  light  in  a  case  of  suppurative 
panophthalmitis ;  however,  this  is  only  a  minor  point  which  plays  no 
important  part  in  the  diagnosis. 

As  to  the  vertigo,  it  was  slight  at  the  time  of  the  examination  but 
had  been  very  intense  several  weeks  previous,  lasting  several  days 
and  gradually  diminishing.  The  memory  of  the  vertigo  was  vivid 
enough  in  both  instances  for  the  patients  to  describe  it  accurately.  One 
patient  described  it  as  a  sensation  of  apparent  turning  of  the  sur- 
rounding objects ;  the  other,  a  sensation  of  apparent  turning  of  him- 
self.t  Both  patients  had  marked  nausea  and  vomiting  as  accom- 
panying symptoms,  and  were  compelled  to  lie  down  in  order  to  feel 


*Actual  deafness  is  rarely  complained  of  in  any  case  having  from  good  to  per- 
fect hearing  in  the  remaining  ear.  The  determination  of  complete  deafness  must 
be  decided  by  the  functional  tests. 

fThe  patient  who  experienced  the  sensation  of  surrounding  objects  turning  was 
more  observing  and  less  neurotic  than  the  patient  who  experienced  only  the  sen- 
sation of  being  turned  himself.  Darkness  before  the  eyes  is  a  late  symptom  of 
vertigo  found  especially  in  neurotic  people. 


L.IRYRIXTH  SUPPURATION— TWO  CASES. 

secure  from  falling  and  to  diminish  the  intensity  of  the  vertigo.  Not- 
withstanding the  fact  that  the  patients  described  their  sensations  some- 
what differently,  the  description  of  one  is  as  characteristic  as 
that  of  the  other  for  vestibular  vertigo  (Drehschwindel  of  the  German 
authors). 

Vesiibnlar  vertigo  then  is  our  first  cardinal  symptom  of  labyrinth 
suppuration,  elicited  from  the  history  of  these  cases. 

Fever  was  difficult  to  determine  and  if  it  had  been  present  must 
have  been  very  slight,  since  the  one  patient  who  believed  she  had  fever 
decided  so  from  the  thirst  she  suffered.  Thirst  is  a  factor  in  de- 
termining fever  only  with  the  laity  and  in  this  case  was  due  more 
to  the  excessive  vomiting  than  to  anything  else.  The  other  patient  was 
inclined  to  the  belief  that  he  had  had  no  fever. 

Headache  was  pronounced  in  both  cases.  I  have  come  to  regard 
headache,  though  not  a  cardinal  symptom,  yet  one  of  importance  in  the 
differential  diagnosis  between  suppurative  and  serous  labyrinthitis. 
The  reason  is  very  apparent;  since  in  the  serous  labyrinthitis  the 
membranes  of  the  brain  are  found  to  be  normal  while  in  the  suppura- 
tive form  I  have  frequently  found  in  early  cases  serous  meningitis. 
These  two  cases  were  no  exception  to  this  rule.  In  addition,  Case  I. 
complained  of  apathy  and  stiffness  behind  the  neck.  Case  II.  com- 
plained of  a  crooked  face  with  inability  to  close  the  left  eye,  indi- 
cating 7th  nerve  palsy. 

Summary  of  the  history  in  both  cases  showed  in  common :  Chronic 
middle  ear  suppuration  of  unknown  origin,  intermittent  discharge  from 
the  ear.  neglected  treatment,  impaired  hearing,  typical  vestibular  vertigo 
and  symptoms  of  headache  indicating  some  form  of  meningitis  or 
meningo-encephalitis. 

From  the  histories  alone  I  was  able  to  make  a  provisional  diagnosis 
of  labyrinth  suppuration,  fixing  the  date  of  the  attack,  and  that 
secondary  meningitis  was  present  at  the  time. 

Otoscopic  findings. 

Both  cases  presented  a  moderate  amount  of  dirty  looking,  fetid, 
purulent  discharge  from  the  left  ear.  The  fetidity  of  the  discharge 
in  these  cases  was  not  so  important  as  in  other  cases  where  the  ear 
had  been  recently  treated.  (Persistent  fetidity  of  the  discharge  after 
thorough  and  repeated  cleanings  should  lead  one  to  suspect  choles- 
teatoma). 

The  external  bony  canal  was  narrowed  in  both  cases,  indicating 
recent  mastoiditis.  Mastoiditis  in  these  cases  was  more  coincidental 
than  characteristic  for  labyrinth  complications  since  I  have  founil  as 
many  cases  free  from  mastoiditis  as  with  it. 

Polyps  were  found  in  both  cases  hanging  downward  from  the  attic- 
antrum  region  into  the  mesotympamim  which  prevented  a  thorough 
inspection  of  the  tympanic  cavity.  I  did  not  remove  these  polyps  in 
order  to  make  a  more  thorough  inspection  of  the  tympanic  cavity  for 


LABYRINTH  PAPERS.  25 

the  following  reason :  It  is  a  safe  rule  never  to  do  a  minor  intra- 
tympanic  operation  (polyp  extraction  or  ossiculectomy)  ivhen  a  radical 
operation  is  otherwise  indicated. 

Tenderness  over  the  mastoid  was  more  or  less  present  in  both  cases 
and  in  one  case  the  periosteum  was  thickened. 

Microscopic  examination  of  the  syringed  out  tympanic  secretion, 
examined  in  the  natural  state  with  a  %  objective,  showed  epidermis, 
pus  cells,  movable  micro-organisms,  debris,  and  in  addition  Case  I 
showed  the  typical  cholestearin  crystals,  indicating  cholesteatoma, 
which  was  later  corroborated  at  the  operation. 

For  a  more  detailed  description  of  cholesteatoma  and  methods  of 
diagnosis,  the  reader  is  referred  to  a  paper  upon  "Cholesteatoma"  by 
the,  writer,  Monatsch.  f.  Ohren.,  1908.  Zur  klinischen  Diagnostik  des 
!\  I  ittelohrcholesteatoms. 

Eye  ground  was  normal  in  Case  II,  and  choked  discs  found  in  both 
«yes  in  Case  I. 

Excepting  for  the  ear  and  head  conditions  the  general  condition 
of  the  patients  was  fair. 

Functional  examination  of  the  ears  showed  both  acoustic  and  non- 
acoustic  functions  to  be  negative  in  the  diseased  (left)  ear  of  both 
patients. 

Conversational  voice  was  heard  from  il/2  to  2  meters  upon  the  left 
side  and  whispered  voice  and  acumeter  ad  conchum  (less  than  20  cm.). 
This  amount  of  hearing  from  the  left  side  does  not  prove  that  the 
patients  actually  heard  with  the  left  ear.  Bezold,  Politzer,  and 
recently  Alexander,  Barany  and  others  have  shown,  in  cases  of  one 
sided  deafness,  that  exclusion  of  the  normal  ear  by  the  ordinary  means 
Of  stopping  up  the  canal  with  a  wet  finger  or  with  paraffine  is  insuf- 
ficient. Repeated  experiments  with  cases  of  absolute  one  sided  deaf- 
ness (cases  where  the  labyrinth  of  that  side  had  been  removed)  show 
apparent  hearing  of  from  I  to  6  meters  distance  for  conversational 
voice.  It  was  therefore  necessary  to  try  other  methods,  the  3  meter 
speaking  tube  recommended  by  Politzer  and  Bezold's  new  small  z.^ 
fork,  manufactured  by  Edelman.  The  telephone  method  and  the  new 
method  of  Barany  were  not  tried. 

'When  the  speaking  tube  shows  more  than  50  %  failures  to  conversa- 
tional voice  and  100  %  failures  to  whispered  voice,  the  Politzer  school 
accepts  such  cases  as  those  of  complete  deafness.  I  have,  however, 
greater  faith  in  the  Bezold  small  at  fork. 

I  make  the  examination  by  striking  the  fork  a  moderate  blow  with  a 
rubber-covered  hammer  so  that  the  fork  can  be  heard  distinctly  at  /  or 
8  inches,  the  width  of  the  skull,  but  no  further.  When  the  fork  thus 
struck  is  held  I  inch  from  the  normal  ear  it  can  be  heard  very  intensely. 
I  have  found  this  method  of  examination  the  best  for  producing  loud 
tones  when  held  close  to  the  ear  and  at  the  same  time  excluding  all 
possibility  of  hearing  from  the  opposite  ear.  I  can  recommend  this  fork 
as  the  best  asset  an  otologist  can  have  for  making  functional  hearing 
tests  for  one  sided  deafness. 


-6  l..UiYKI\TH  SUPPURATION—TWO  CASES. 

The  low  Q  was  not  heard,  and  the  high  c4  was  heard  but  very  much 
shortened.  These  high  tone  forks  are  always  unreliable  tests  for  one 
sided  deafness  since  they  can  be  heard  at  very  long  distances  and 
have  great  power  of  penetration. 

The  remaining  tests — negative  Rhine,  with  the  middle  C  with  no 
air  conduction  and  very  much  shortened  bone  conduction ;  Weber  to 
the  better  ear  ;*  Schwabach  very  short ;  negative  watch  on  bone  are 
the  same  results  as  obtained  in  every  case  I  have  examined. 

From  the  above  functional  test  findings  we  must  conclude  that  both 
patients  were  absolutely  deaf  on  the  left  side ;  this,  therefore,  makes 
a  second  positive  sign  or  symptom  of  labyrinth  suppuration — Absolute 
deafness. 

i:\.\MIXAT[ON  OF  THE  NONACOUSTIC  l.AI'.Y  KI  NTH. 

Both  cases  showed  pronounced  spontaneous  rotatory  nystagmus  to 
the  sound  (right)  side  upon  the  patients  looking  to  the  right;  less 
marked  horizontal  and  mixed  horizontal  and  rotatory  nystagmus  to  the 
left  si<Je  upon  looking  to  the  left,  and  slight  but  evident  spontaneous 
rotatory  nystagmus  to  the  right  side  when  looking  straight  ahead ; 
however,  in  determining  this  last  form  of  nystagmus  it  was  necessary 
in  one  of  the  cases  to  use  the  opaque  spectacles. 

The  above  findings  are  characteristic  of  late  labyrinth  suppuration 
after  the  first,  second  or  third  week.  In  acute  cases,  however,  the 
nystagmus  is  constantly  rotatory  and  to  the  sound  side  in  all  positions 
of  the  eyeballs.  Most  marked  when  looking  to  the  sound  side,  less 
marked  when  looking  straight  ahead  and  least  marked  when  looking  to 
the  diseased  side.  This  nystagmus  gradually  diminishes,  and  after  a 
few  weeks  changes  to  the  character  as  recorded  above  and  presented 
by  the  cases  here  reported. 

The  rotatory  nystagmus  to  the  sound  side  when  looking  straight 
ahead  I  consider  the  most  important  and  characteristic  spontaneous 
nystagmus  of  late  labyrinth  suppuration. 

In  making  the  examination  for  spontaneous  nystagmus  in  the 
straight  ahead  position  of  the  eyeballs,  it  is  necessary  first  to  have  the 
patient  look  at  a  distant  object  or  else  use  the  opaque  spectacles  to 
prevent  convergence,  which  inhibits  the  vestibular  reflex ;  second,  ele- 
vate the  lids  sufficiently  (preferably  with  the  thumb  of  the  left  hand 
when  examining  the  right  eye  and  vice  versa  when  examining  the  left 
eye)  to  observe  a  fair  portion  of  the  sclera  above  the  cornea  (see  Fig. 
i)  ;  third,  a  good  light  thrown  upon  the  eyeball  which  helps  us  to  see 

*Neumann,  of  Vienna,  has  told  to  his  classes  that  he  had  observed  in  at  least 
two  cases  of  one  sided  labyrinth  destruction,  Weber  lateralized  to  the  diseased 
side.  These  were  cases  of  total  sequestration  of  the  labyrinth.  He  believes  that  in 
cases  of  one  sided  labyrinth  destruction,  secondary  to  middle  ear  disease,  with 
complete  loss  of  acoustic  and  static  functions,  that  Weber  to  the  diseased  side  in- 
dicates a  perilabyrinthitis. 


LABYRINTH  PAPERS. 


27 


well  and  at  the  same  time  makes  a  reflex  upon  the  eye  which  gives  us  a 
stationary  point  by  which  we  can  estimate  the  movements  of  the  eye- 
ball by  the  change  of  relationship  between  the  reflex  and  one  of  the 
prominent  vessels  of  the  sclera. 

The  intensity  of  vestibular  nystagmus  is  proportionate  to  the  fre- 
quency of  the  movements  and  the  length  of  the  excursions.  From 
this  we  can  appreciate  the  ease  of  determining  the  character  and  di- 


FlG.l. 


Illustrates  a  method  of  examination  of  nystagmus  of  slight  degree.  Since  the 
voluntary  action  of  the  III  nerve  in  accommodation  and  convergence  inhibits  the 
vestibular  reflex  through  the  Deiter's  system,  Abels  suggested  the  use  of 
the  opaque  spectacles.  The  spectacles  are  used  also  in  making  more  accurate 
examinations  of  the  horizontal  after-turning  nystagmus.  The  spectacles  are 
fitted  upon  the  patient  as  the  ordinary  spectacles  are,  the  patient  is  directed  to 
look  straight  ahead  into  vacancy  and  with  the  head  slightly  tilted  backward,  the 
thumb  used  to  elevate  the  upper  lid,  we  observe  the  nystagmic  movements  of 
eyes  over  the  top  and  side  of  the  spectacles. 

rection  of  the  nystagmus  in  an  acute  case  and  the  difficulty  of  de- 
termining the  nystagmus  in  a  late  case.  However,  exercise  in  ex- 
amining a  number  of  cases  will  make  one  quite  proficient  after  a 
short  time.  In  the  cases  here  reported  the  length  of  the  excursions 
was  approximately  2  mm.  and  the  frequency  about  5  seconds;  a 
casual  glance  would  not  suffice  to  recognize  it.  This  type  of  nystagmus 


2S  LABYRINTH  SUPPURATION— TWO  CASES. 

is  characteristic  of  late  labyrinth  suppuration.  Thus  we  have  our 
third  cardinal  symptom  or  sign — Spontaneous  rotatory  nystagmus  to 
the  sound  side. 

Disturbances  of  equilibrium  belonging  to  the  late  form  of  labyrinth 
suppuration  were  present. 

It  will  be  remembered  from  the  former  paper  that  I  referred  to  an 
early  and  a  late  form  of  disturbance  of  equilibrium.  The  case  here 
reported  could  naturally  show  only  the  late  form  ;  which  was  evidenced 
by  a  slight  but  positive  Rhomberg:*  broad  and  uncertain  gait  with 
closed  eyes  when  walking  forward  and  backward;  unsteadiness  was 
very  pronounced  by  side  gait  and  hopping  on  one  foot  with  closed  eyes. 
The  Alexander-Stein  goniometer  showed  diminished  ability  to  maintain 
equilibrium.  According  to  Stein,  a  normal  person  can  tolerate  an  eleva- 
tion on  the  inclined  plane  of  from  30°  to  34°  when  the  face  is  forward, 
backward  or  to  the  sides  and  with  closed  eyes,t  but  in  these  cases  the 
figures  fell  much  below  the  normal ;  thus,  we  have  a  fourth  symptom 
of  labyrinth  suppuration — Disturbance  of  equilibrium. 

The  examination  of  the  nonacoustic  labyrinth  was  made  after  three 
methods — I,  caloric;  2,  after-turning;  3,  galvanic. 

I.  The  caloric  examination  elicited  no  reaction  from  the  diseased 
ear  in  either  case. 

In  making  the  caloric  examination  I  use  a  Hartman's  canula 
fitted  on  a  rubber  tube  about  25  cm.  long,  to  the  other  end  of  which 
is  attached  a  10  oz.  Politzer  bag  filled  with  cold  water  (about  20°  C). 
I  prefer  the  use  of  cold  water,  since  the  reaction  when  present  is  more 
prompt  and  more  certain  than  when  hot  water  is  used.  The  applica- 
tion of  cold  water  is  best  made  by  an  assistant  and  the  observation  of 
the  reaction  (nystagmus  to  the  opposite  side)  by  the  surgeon.  After 
first  squeezing  out  the  air,  the  tip  of  the  canula  is  introduced  through 
the  external  canal  into  the  tympanic  cavity.  A  good  light  and  a 
speculum  are  essential  aids  for  the  successful  introduction  of  the 
canula. 

The  observer's  position  is  in  front  of  the  patient  with  a  head  mirror 
directing  the  illumination  upon  the  eye;  with  the  thumb  of  the  left 
hand  the  upper  eyelid  is  raised  to  better  expose  the  eyeball  (see  Fig. 
2).  At  the  moment  of  appearance  of  reaction,  stop  the  stream  of  cold 
water  and  begin  to  neutralize  the  effect  with  hot  water  (42°  C.).  The 
neutralizing  is  done  with  hot  water  to  cut  short  any  unpleasant  symp- 
toms of  vertigo  and  vomiting,  which  otherwise  frequently  continue  for 
some  time.  It  is  worth  mentioning  that  the  nystagmus  precedes  the 
vertigo  by  a  few  seconds  and  that  low  degrees  of  nystagmus  can  be  ob- 

*Rhomberg  test  is  the  least  accurate  of  all  equilibrium  tests. 

I  make  all  tests  with  patients  standing  in  bare  feet,  since  the  shoes  in  sonic 
instances  are  an  aid,  but  more  often  a  hindrance,  in  the  effort  of  the  patient  to 
maintain  equilibrium. 


LABYRINTH  PAPERS. 


29 


tained  without  much  vertigo.     The  above  reaction  applies  only  when 
making  examinations  with  the  head  in  the  upright  position. 

This  method  of  examination  is  satisfactory  enough  in  late  cases  of 
labyrinth  suppuration  where  the  nystagmus  is  slight;  but  not  in  a 
recent  case,  since  a  recent  labyrinth  suppuration  has  pronounced 
rotatory  nystagmus  to  the  sound  side  and  the  reaction  from  the  use 


FIG.&. 


P,  Patient  is  looking  straight  ahead  at  some  distant  object,  as  directed; 
A,  assistant  syringing  ear  using  the  Hartmann's  canula,  H,  and  P  B,  Politzer  bag 
filled  with  water  to  be  syringed.  B,  pus  bag  to  collect  the  waste  water  and  dis- 
charges from  the  ear.  E,  examiner  raising  the  upper  eyelid  with  thumb,  T,  to 
better  observe  the  nystagmic  movements  of  the  eyes. 

This  method  can  be  improved  upon  if  one  uses  a  fountain  syringe,  then  the 
left  hand  can  be  used  to  hold  speculum  in  place,  the  right  hand  to  direct  the 
canula. 

of  cold  water  could  only  increase  the  nystagmus ;  this  allows  a  chance 
for  an  error  of  observation  in  determining  a  positive  reaction.  It  is 
therefore  more  satisfactory  in  such  acute  cases  with  pronounced  ro- 
tatory nystagmus  to  the  sound  side  to  make  the  caloric  reaction  with 
cold  water  as  described,  but  with  the  head  in  the  horizontal  position ; 


30  I..tH}'KI.\Til  SUPPURATION— TWO  C.ISES. 

for  example — the  right  side  of  the  face  upon  the  right  shoulder  when 
examining  the  left  ear,  when  a  positive  reaction  is  indicated  by  a  hori- 
zontal nystagmus  to  the  diseased  side  (left). 

In  the  case  here  reported  no  caloric  reaction  was  obtainable  after  3 
minutes'  continuous  flow  of  cold  water  in  the  tympanic  cavity ;  thus, 
we  have  our  fifth  sign  of  labyrinth  suppuration — Xcgativc  caloric  re- 
action. 

2.  Diminished  or  Negative  reaction  to  turning. 

Diminished  or  negative  nystagmus  after  turning  would  be  a 
more  corect  way  of  expressing  the  reaction  and  hereafter  I  shall 
adopt  the  term  "After-nystagmus"  which  is  the  literal  translation  of 
"Nach-nystagmus"  of  the  German  literature  (Barany).  Another 
reason  for  abandonment  of  the  former  term  is  that  when  speaking  of 
diminished  reaction  to  turning  one  may  be  misunderstood  to  mean 
that  in  labyrinth  suppuration  there  is,  though  diminished,  a  posi- 
tive reaction  from  the  diseased  labyrinth,  whereas  the  fact  is  there  is 
no  reaction  from  the  diseased  labyrinth  and  the  nystagmus  which  is 
present  toward  the  diseased  side  (after  turning  to  the  well  side)  is 
due  to  the  normal  physiological  reaction  of  the  opposite  (well)  side. 

\Yhile  upon  the  subject  a  brief  explanation  is  opportune.  Ewald 
was  the  first  to  prove  the  physiology  of  the  semicircular  canals  by 
means  of  a  pneumatic  hammer  fitted  into  an  opening  made  in  the 
bony  horizontal  semicircular  canal  of  a  pigeon,  permitting  the  mem- 
branous labyrinth  to  remain  intact ;  he  was  able  to  cause  a 
flow  in  the  endolymph  from  the  smooth  end  toward  the  ampulla  by 
pressure,  and,  from  the  utriculus  and  ampulla  toward  the  smooth 
end  by  suction.  He  found  furthermore  that  the  flow  of  the  endo- 
lymph from  the  smooth  end  towards  the  ampulla  caused  a  move- 
ment of  the  cupola  and  an  inclination  of  the  cilia  of  the  neuro- 
epithelia  in  the  ampulla  towards  the  utriculus  and  with  it  a  horizontal 
nystagmus  of  considerable  intensity  towards  the  same  side;  while  a 
flow  of  the  endolymph  in  the  opposite  direction  caused  the  opposite 
effect  (a  horizontal  nystagmus  of  less  intensity  towards  the  opposite 
side).  In  brief,  the  semicircular  canals  of  one  side  are  capable  of 
producing  nystagmus  to  both  sides,  depending  upon  the  direction  of 
the  endolymph  current,  but  stronger  to  the  same  than  to  the  opposite 
side:  so  that  in  case  of  total  destruction  of  one  side  we  can  obtain 
a  nystagmus  to  the  diseased  side,  but  much  diminished  in  intensity 
and  duration. 

Since  the  semicircular  canals  of  one  side  can  produce  nystagmus  to 
•either  side  but  more  pronounced  to  the  same  than  to  the  opposite  side, 
and  since  by  rotation  of  the  head  both  labyrinths  are  brought  into 
function,  it  must  follow  that  in  a  case  of  left  labyrinth  suppuration 
( destruction),  the  nystagmus  to  the  left  side  is  greatly  diminished  and 
the  nystagmus  to  the  right  side  but  slightly.  These  facts  are  further- 
more borne  out  l.y  the  experience  of  all  who  have  investigated  after- 
turning  nystagmus. 


LABYRINTH  r.ll'l'RS.  31 

The  examination  is  made  with  the  patient  sitting  upon  the  revolving 
stool  as  seen  in  Fig.  3. 

^  The  patient  sits  in  the  chair  while  the  examiner  revolves  it  10 
times,*  then  suddenly  brings  it  to  a  stop  and,  with  a  stopwatch  times 
the  duration  of  the  after-nystagmus.  The  examination  for  horizontal 
after-nystagmus  should  be  made  by  turning  the  patient  with  the  head 
in  the  upright  position,  while  the  examination  for  rotatory  after-nystag- 


Fi  G  3. 


P,  patient;  E,  examiner;  S,  revolving  stool;  B,  bearing,  substituted  for  the 
ordinary  screw,  permitting  rotation  of  the  stool  without  the  elevation  or  lowering 
which  occurs  when  the  stool  is  fitted  with  a  screw.  H,  handle.  In  the  figure  the 
patient  is  in  a  position  (head  forward")  to  produce  rotatory  nystagmus  by  turn- 
ing or  after  stopping  turning.  The  eyes  are  closed  to  avoid  optical  nystagmus. 

mus  should  be  made  with  the  head  inclined  forward  90°,  as  in  Fig. 
3;  however,  the  observation  of  the  rotatory  after-nystagmus  is  made 

*Turning  ten  times  has  been  largely  adopted  instead  of  a  greater  or  less  num- 
ber of  times  for  evident  reasons.  See  Barany,  "Physiologic  und  Pathologic,  des 
Bogengang  Apparates  beim  Menchen." 


32  L.IHYRIXTH  SUPPURATION— TWO  CASES. 

with  the  head  upright.  In  other  words,  we  may  change  the  position 
of  the  head  from  the  forward  to  the  upright  position  after  turning 
without  changing  the  character  of  the  nystagmus. 

The  duration  of  the  after-nystagmus  varies  greatly ;  in  normal  peo- 
ple the  average  being  J(>  seconds  for  rotatory  and  35  seconds  for  the 
horizontal.  A  diminution  to  12  seconds  for  either  horizontal  or  ro- 


H 


Fic.4 


P,  patient;  A,  assistant  who  runs  the  switch,  C,  and  reads  the  milliamperage 
from  the  milliamperemeter  M;  E,  examiner;  H,  head  mirror  to  illuminate  the  eye; 
e  and  e',  electrodes.  The  wall  plate  should  show  a  reversing  switch  to  change 
the  polarity  without  changing  the  electrodes. 

tatory  after-nystagmus  is  an  indication  of  destroyed  function  upon 
that  side,  and  according  to  some  a  diminution  to  15  seconds  is  suffi- 
cient for  a  diagnosis.  I  am  more  conservative,  however,  since  I 
found  two  cases — one  with  14  seconds  and  one  with  13  seconds'  dura- 
tion— where  the  labyrinths  were  still  in  function. 

In  the  cases  before  us  the  longest  duration  for  the  after-nystagmus 


LABYRINTH  PAPERS.  33. 

to  the  diseased  side  was  9  seconds  in  one  of  the  cases  for  the  horizontal 
nystagmus  with  the  opaque  spectacles.  Such  low  figures  are  never 
found  in  a  reacting  labyrinth,  and  with  even  lower  figures  for  the 
rotatory  after-nystagmus  clinches  the  fact  that  the  nonacoustic  laby- 
rinths upon  the  diseased  side  were  destroyed.  Thus,  the  sixth  symp- 
tom or  sign  of  labyrinth  suppuration  present  in  these  cases — Diminish- 
ed after-nystagmus  to  the  diseased  side. 

3.  The  Galvanic  reaction  in  both  cases  shows  a  characteristic  diminu- 
tion of  irritability  upon  the  diseased  side.  Normally  from  4  to  6  ma. 
applied  with  a  small  ball  electrode  i  cm.  in  diameter  just  in  front  of 
and  above  the  tragus  (see  Fig.  4)  will  produce  a  nystagmus  (with 
vertigo)  to  the  side  of  the  kathode  when  the  kathode  is  used,  and  to  the 
opposite  side  when  the  anode  is  used.  A  reaction  with  less  than  4  ma, 
with  the  kathode  indicates  over-irritability  of  that  side  or  destruction 
of  the  opposite  side.  A  reaction  which  requires  more  than  8  ma.  in- 
dicates loss  of  function  in  the  static  labyrinth  of  that  side  or  over-irri- 
tability of  the  opposite  side. 

The  question  which  would  naturally  suggest  itself  to  the  average- 
reader  is — Why  should  we  conclude  that  there  is  destruction  in  the 
labyrinth  when  we  can  obtain  a  positive  reaction  with  8  ma.  with  the 
kathode  to  the  diseased  side?  The  answer  is  that  in  such  cases  the 
positive  reaction  is  obtained  from  the  nerve  and  not  from  the  end 
organ  in  the  semicircular  canals. 

The  Galvanic  reaction  is  so  large  a  subject  that  a  thorough  dis- 
cussion of  it  would  take  up  too  much  space  for  this  paper.  I  shall 
therefore  reserve  for  another  paper  upon  "Differential  Diagnosis"  a 
thorough  discussion  of  the  Galvanic  reaction,  where  it  plays  a  more- 
important  role. 

In  brief,  the  characteristic  reaction  for  labyrinth  destruction  of  not 
too  long  standing  is  : 

Left  Ear  (labyrinth  suppuration). — Kathode,  8  to  10  ma.,  no  re- 
action or  slightly  positive  rotatory  nystagmus  to  left  side.  Anode,  2 
ma.,  rotatory  nystagmus  to  right  side. 

Right  Ear  (normal). — Kathode,  2  ma.,  rotatory  nystagmus  to  right 
side.  Anode,  8  ma.,  no  reaction  or  slightly  positive  rotatory  nystag- 
mus to  the  left  side. 

Again,  if  the  kathodal  reaction  to  the  diseased  side  requires  more 
than  twice  the  number  of  milliamperes  as  that  to  the  normal  side  we 
may  conclude  that  there  is  loss  of  function  upon  the  diseased  side. 

The  Galvanic  reaction  in  the  cases  presented  is  characteristic  for 
the  labyrinth  suppuration ;  hence  our  last  positive  symptom  or  sign 
of  labyrinth  suppuration — Diminished  or  negative  Galvanic  reaction 
upon  the  diseased  side. 

The  operation,   the   subsequent   treatment  and   results    require  no 
special  discussion  and  are  sufficiently  clear  to  speak  for  themselves. 
3 


34  LABYRINTH  SUPPURAT1OX— TWO  CASES. 


SUMMARY. 

I.  All  symptoms  and  signs  were  positive  for  the  diagnosis  of  laby- 
rinth suppuration. 

II.  Symptoms  and  signs  were  present  sufficiently  characteristic  to 
warrant  a  diagnosis  of  meningitis  and  exposure  and  examination  of 
the  membranes  at  the  time  of  operation. 

III.  The  operations  consisted  of  the  radical  Kuester-Bergmann  plus 
thorough  opening  of  the  labyrinth  and  the  operation  for  serous  menin- 
gitis recommended  by  Koerner  and  Alexander. 

IV.  With  the  exception  of  facial  palsy,  which  is  rapidly  improving, 
both  cases   experienced   early   improvement   of  meningeal    symptoms 
.after  operation  and  ultimately  were  discharged  cured. 


LABYRINTH  SUPPURATION— DIFFERENTIAL 
DIAGNOSIS, 

WHILE  the  otologists  are  paying  increased  attention  to  the 
subject  of  labyrinth  suppuration  it  is  well  that  we  pay 
even  greater  attention  to  the  subject  of  differential  diag- 
nosis, for  with  the  advances  made  in  its  surgical  treatment  there  is  the 
danger  that  some  of  us.  in  our  enthusiasm  to  operate,  may  sacrifice 
unnecessarily  labyrinths  of  patients  (presenting  the  history  of  chronic 
suppuration  and  the  symptoms  of  vertigo,  nystagmus  and  disturbance 
of  equilibrium  )   who  would  otherwise  recover  spontaneously. 

It  is  an  appreciation  of  these  dangers  which  prompts  the  writer  in 
the  presentation  of  this  paper  upon  Differential  Diagnosis.  Of  all  the 
cases  presenting  the  above  history  and  symptoms  only  a  relatively  small 
per  cent,  are  suffering  from  labyrinth  suppuration. 

We  shall  consider  only  those  affections  of  the  labyrinth  secondary  to 
acute  or  chronic  middle  ear  suppuration  which,  by  reason  of  the  symp- 
toms of  impaired  hearing,  vertigo,  nystagmus  and  disturbance  of 
equilibrium,  may  be  confounded  with  labyrinth  suppuration.  They 
may  be  divided  into : 

I. — Affections  of  the  membranous  labyrinth : 
I     i. — Diffuse  hyperemia. 

.A. — Diffuse 

(^        suppuration). 

C   i. — Circumscribed  irritative  lesion  of  the  mem- 
branous labvrinth. 
n. — Circumscribed  {  ~.  ..     .  ,  .    .         ,  .. 

•     2. — Circumscribed  destructive  lesion  of  the  mem- 

j        branous  labyrinth. 

II. — Affections  of  the  bony  labyrinth    (erosions,    caries,    necrosis. 

fistuke,  etc.). 

III. — Affections  of  the  perilabyrinthine  spaces  (perilabyrinthitis  with 
resulting  sequestration  of  a  part  or  the  entire  labyrinth. 

I,  A.  i. — DIFFUSE  HYPEREMIA  OF  THE  LABYRINTH  may  be  met  with 
un  the  course  of  acute  or  chronic  middle  ear  suppuration.  The  opinion 


,     2. — Diffuse  serous  labyrinthitis. 
"]     3. — Diffuse  suppurative  labyrinthitis    (labyrinth 


36  DIFFERENTIAL  DIAGNOSIS. 

of  some  authors  is  that  every  acute  middle  ear  inflammation  is  attended 
with  more  or  less  hyperemia  of  the  labyrinth,  while  others  believe  that 
the  labyrinth  symptoms  are  due  rather  to  the  pressure  of  confined  se- 
cretion upon  the  windows;  it  would  seem  that  both  views  are  in  a 
measure  correct.  In  support  of  the  first  view  we  know  of  cases  of  acute 
infections  of  the  ear  where  the  greater  force  of  the  infection  has  been 
felt  in  the  labyrinth  (especially  infection  from  streptococcus  mucosa) 
with  resulting  labyrinth  suppuration  and  meningitis,  whereas  the  mid- 
dle ear  affection  remained  so  mild  that  it  did  not  lead  to  even  perfora- 
tion of  the  membrane ;  while  on  the  other  hand,  in  support  of  the 
second  view,  there  are  cases  of  severe  acute  otitis  media  with  asso- 
ciated labyrinthine  symptoms  which  are  promptly  relieved  by  para- 
centesis  of  the  membrane. 

Aside  from  the  cases  of  panotitis  which  terminate  fatally  within  a 
few  days  after  the  onset  of  acute  otitis  media,  the  opinion  of  the  writer 
is  that  every  acute  middle  ear  inflammation  is  accompanied  by  more  or 
less  congestion  of  the  labyrinth ;  its  intensity  varying  in  proportion  to 
the  virulence  of  the  infecting  micro-organism. 

Hyperemia  of  the  labyrinth  may  occur  too  in  the  course  of  chronic 
middle  ear  suppuration,  especially  during  periods  of  acute  exacerba- 
tions. The  cause  in  this  instance  is  not  exactly  known.  It  is  probably 
due  to  toxins  generated  by  the  infection  in  the  middle  ear  which  find 
their  way  into  the  labyrinth. 

Hyperemia  and  the  symptoms  of  hyperemia  may  begin  suddenly  like 
those  of  labyrinth  suppuration,  in  spite  of  which  and  the  fact  that  they 
have  several  symptoms  in  common,  the  two  processes  are  very  unlike ; 
for  in  hyperemia  we  have  an  irritative  process  with  increased  re- 
actibility;  while  in  suppuration  we  have  a  destructive  process  with 
negative  reactibility. 

A  comparison  of  the  two  processes  shows  the  following : — 

HYPEREMIA  OF  THE  LABYRINTH.  SUPPURATION  OF  THE  LABYRINTH 

I. — Impairment     of     hearing      in-       i. — Absolute  deafness. 
creased. 

2. — Tinnitis.  2. — No  tinnitis. 

3. — Moderate   vertigo,   aggravated      3. — Intense    vertigo,     but    con- 
in  recumbent  position.  stantly    diminishing    and    re- 
lieved in  recumbent  position. 


LABYRINTH  PAPERS.  37 

4. — Spontaneous  nystagmus  to  4. — In  acute  stage  nystagmus  to 
both  sides,  but  more  marked  to  the  well  side  only ;  later  stages 
the  the  diseased  side.  it  may  be  to  both  sides,  but 

always   more    marked   to   the 
•Lcell  side. 
5. — Irritability     of     the     labyrinth       5. — Irritability  of  the    labyrinth 

increased.  negative. 

6. — Disturbance  of  equilibrium  not  6. — Disturbance  of  equilibrium 
so  pronounced  as  in  suppuration  very  pronounced  in  the  acute 
of  the  labyrinth.  stage  ;  present,  though  mod- 

erate, in  the  last  stage. 

7. — Ultimate  recovery  of  acoustic  7. — Permanent  loss  of  acoustic 
and  static  functions.  and  static  functions. 

The  increased  reactibility  of  the  labyrinth  in  hyperemia  is  determined 
by  the  turning  and  galvanic  test  (quantitative  tests).  Since  the  caloric 
test  can  be  only  positive  or  negative,  it  becomes  purely  a  qualitative 
test,  and  can  not  be  used  as  a  quantitative  one. 

The  increased  reactibility  of  the  labyrinth  is  manifested  by  an  in- 
crease in  the  duration  of  the  after-nystagmus  to  the  diseased  side;  for 
example — if  the  right  labyrinth  is  over  irritable  we  have  an  after- 
nystagmus  to  the  right  lasting  from  40  to  100  seconds  or  more,  while 
the  after-nystagmus  to  the  left  remains  about  the  normal  figures,  say 
from  18  to  35  seconds.  It  may  also  happen  in  cases  where  one  laby- 
rinth is  very  markedly  pathologically  irritated,  that  the  after-nystagmus 
to  the  well  side  is  also  relatively  increased. 

The  galvanic  reaction  in  case  of  hyperemia,  say  of  the  right  labyrinth, 
shows  that  the  right  labyrinth  with  kathode  to  the  right  ear  responds 
to  irritation  with  less  milliamperage  than  the  opposite  (well)  ear.  In 
addition  to  the  above  signs  I  have  frequently  found  in  cases  of  hyper- 
emia of  the  labyrinth  associated  with  acute  middle  ear  inflammation,  a 
marked  compression  and  aspiration  nystagmus,  a  symptom  never  found 
in  suppuration  of  the  labyrinth. 

This  compression  and  aspiration  nystagmus  in  acute  cases  may  be 
found  before  perforation,  or  after  when  the  perforation  is  very  small. 
I  believe  it  is  due  to  the  hydraulic  pressure  of  the  secretion  in  the  middle 
ear  upon  the  windows  being  greater  than  the  pneumatic  pressure  when 
the  middle  ear  is  in  the  normal  state.  Furthermore,  in  the  acute  in- 
flammatory conditions  the  pressure  of  the  secretion,  by  reason  of  the 


38  DIFFERENTIAL  DIAGNOSIS. 

closure  of  the  Eustachian  tube  by  inflammatory  swelling,  is  confined 
more  to  the  walls  of  the  tympanic  cavity,  while  in  the  normal  state  the 
pressure  is  not  so  confined  to  the  middle  ear  but  escapes  appreciably 
through  the  patulous  Eustachian  tube. 

The  differential  diagnosis  of  serous  from  suppurative  labyrinthitis. 
may  be  quite  difficult. 

I,  A,  2. — SEROUS  LABYRINTHITIS. 

Serous  Labyrinthitis  is  a  serous  inflammation  of  the  membranous- 
labyrinth  produced  by  the  presence  of  toxins,  while  suppurative  laby- 
rinthitis is  due  to  the  infecting  micro-organisms  themselves.  In  serous 
labyrinthitis  we  have  a  serous  or  a  mildly  serofibrinous  exudate  into 
the  labyrinth,  which  later  may  become  partially  or  completely  resorbed 
with  corresponding  restoration  of  function.  In  suppurative  labyrinth- 
itis we  have  a  violent  inflammation  of  the  labyrinth  with  the  formation 
of  pus,  resulting  in  total  and  permanent  destruction  of  the  membranous 
labyrinth  with  loss  of  function. 

The  prognosis  in  serous  labyrinthitis  is  generally  favorable ;  the  re- 
sult being  a  partial  or  complete  restoration  of  function  :  notwithstanding 
this,  a  serous  labyrinthitis  is  often  the  precursor  of  a  suppurative  laby- 
rinthitis, a  fact  we  should  reckon  with  in  considering  the  treatment. 
At  their  height  the  two  processes  are  very  similar,  the  symptoms  and 
signs  are  perhaps  not  quite  so  pronounced  in  the  serous  as  in  the  sup- 
purative form. 

A  sign  of  importance  in  differential  diagnosis  which  I  have  noted  is 
the  headache,  of  meningeal  type,  present  in  suppurative  labyrinthitis, 
which  is  absent  in  the  serous.  This  headache  is  due  to  irritation  or 
serous  inflammation  of  the  meninges,  termed  by  some  few  writers  as 
meningismus,  but  accepted  by  most  as  a  serous  meningitis.  This  head- 
ache appears  very  early,  often  obscured  somewhat  at  the  beginning  by 
the  intense  vertigo.  Aside  from  the  headache  and  the  difference  in 
the  courses  of  the  two  processes  we  have  nothing  else  to  aid  us  in  the 
differential  diagnosis.  These  facts  can  be  best  illustrated  by  the  com- 
parison of  the  two  tables  below,  showing  the  symptoms  and  the  course 
of  the  two  processes : 


LABYRINTH  PAPERS.  39 

DIFFUSE   SUPPURATIVE    LABYRINTHITIS. 


STAGES                        I 

II 

Ill 

IV 

V 

Normal  con- 
dition before 
labyrinth  in- 
volvement. 

Prodrom  al 
or  irritative       Qnset  of 
stage;     may                    j 
last  from  few      g^ 
weeks  to  sev- 
eral years. 

From  several 
days  to  sev- 
eral     weeks 
after  onset. 

End  stage; 
destruction 
of  functions. 

Hearing. 

+ 

+ 
But 
diminished. 

— 

— 

— 

Tinnitus 

— 

+ 
Periodic. 

— 

— 

— 

Vertigo. 

— 

+ 
In  attacks 

+ 
Intense 

+ 
Only  during 
rapid   move- 
ment of 
head. 

— 

Spontaneous 
Nystagmus. 

— 

To  both 
sides;  more 
marked    to 
diseased  side 

Intense  to 
well  side 
only. 

Both    sides  ; 
more  intense 
to  well  side. 

— 

Irritability  of 
the  static 
labyrinth. 

Normal 

+ 
and  in- 
creased. 

— 

— 

— 

DIFFUSE    SEROUS    LABYRINTHITIS. 


STAGES 

I 

II 

Ill 

IV 

V 

Normal  con- 
dition before 
labyrinth  in- 
volvement. 

Prodromal 
or  irritative 
stage. 

Onset  of 
serous  laby- 
rinthitis. 

Stage  of 
improve- 
ment. 

Recovery 

Hearing. 

+ 

_!_ 
But 
diminished. 

— 

+ 
But 
diminished. 

+ 

DIFFERENTIAL  DIAGNOSIS. 
DIFFUSE   SEROUS   LABYRINTHITIS. —  (Continued.) 


STAGES 

I 

II 

III 

IV 

V 

Tinnitus. 

— 

+ 
Periodic. 

— 

+ 

— 

Vertigo. 

— 

+ 
In  attacks. 

+ 
Intense 

+ 
Only  by 
rapid   move- 
ment  of  the 
head. 

— 

Spontaneous 
Nystagmus. 

— 

To  both 
sides;     more 
marked  to 
diseased  side 

Intense  to 
well  side 
only. 

To  both 
sides;  more 
marked  to 
diseased  side 

— 

Irritability  of 
the  static 
labyrinth. 

Normal. 

+ 
and 
increased 

— 

+ 
with   caloric 
test. 

Normal  or 
nearly   so. 

The  above  tables  represent  fairly  accurately  the  course  of  these  two 
processes.  I  have  presented  stage  I  as  the  normal  condition ;  stage  II 
the  stage  of  iritation  and  of  prodromes.  Although  both  serous  and 
suppurative  labyrinthitis  have  a  sudden  onset,  they  are  preceded  'by  a 
longer  or  shorter  period  of  irritation  with  attacks  of  vertigo  and  nystag- 
mus to  the  well  side.  Ill  is  the  stage  of  attack  with  sudden  onset,  ac- 
companied by  deafness,  intense  vertigo  and  nystagmus  to  the  well 
side  and  negative  reaction  of  the  static  labyrinth.  These  stages  are 
•more  or  less  sharply  defined,  and  up  to  and  including  stage  III  the  two 
conditions  are  clinically  alike  with  the  exception  of  headache  in  the 
suppurative  form,  already  mentioned  above.  After  stage  III  the  two 
processes  begin  to  differ  and  eventually  in  stage  V  we  have  the  end 
stage  of  suppuration,  complete  loss  of  acoustic  and  static  functions, 
while  stage  V  of  serous  labyrinthitis  records  the  normal  findings  or 
those  existent  before  the  attack,  as  in  stage  I. 

The  differentiation  of  these  two  forms  of  labyrinthitis  is  quite  difficult 
until  stage  III  has  passed,  and  where  there  is  doubt  it  may  be  well  to 
wait  a  few  days  or  a  week  after  the  onset  before  deciding  upon  the 
treatment.  If  there  is  much  headache  or  other  signs  of  meningeal  ir- 


LABYRINTH  PAPERS.  41 

ritation,  we  may  safely  consider  the  case  as  one  of  suppurative  laby- 
rinthitis.  On  the  other  hand,  if  headache  or  signs  of  meningeal  irrita- 
tion are  absent,  it  is  not  at  all  dangerous  to  wait,  even  though  it  be  a 
case  of  suppurative  labyrinthitis. 

In  considering  the  .differentiation,  a  fact  worth  bearing  in  mind  is 
that  the  suppurative  labyrinthitis  is  much  more  frequent  than  the 
serous.  Although  serous  labyrinthitis  may  be  the  precursor  of  the  sup- 
purative form,  every  attack  of  the  suppurative  labyrinthitis  need  not 
be  preceded  by  an  attack  of  serous  labyrinthitis. 

I,  B. — CIRCUMSCRIBED  LABYRINTHITIS. 

Circumscribed  labyrinthitis,  secondary  to  middle  ear  suppuration,  oc- 
curs with  the  bony  labyrinth  intact  and  too  when  not  intact.  When 
intact  we  have  either  a  metastatic  or  toxic  condition  from  extension  of 
the  infection  or  the  toxins  of  infection  by  way  of  the  lymph  vessels  or 
by  a  thrombotic  condition  of  the  mucous  membrane  of  the  middle  ear 
extending  through  the  vascular  system  of  the  bone  into  the  labyrinth. 
(Macewen,  Infectioes  Erkranknng  u.  s.  w.,  Wiesbaden,  1898.)  More 
often  circumscribed  labyrinthitis  occurs  when  the  labyrinth  capsule  is 
not  intact;  that  is  to  say,  when  there  is  some  destructive  process  (caries, 
necrosis,  osteoporosis  or  pressure  atrophy,  etc.)  of  the  labyrinth  cap- 
sule, due  to  cholesteatoma  or  tuberculosis;  the  latter  condition  espe- 
cially in  the  first  few  years  of  life.  The  most  frequent  site  is  the 
prominence  of  the  horizontal  semicircular  canal ;  the  next  moNst  fre- 
quent site  is  the  oval  window ;  less  frequent,  the  promontory ;  how- 
ever, any  part  of  the  external  wall  may  be  involved.  These  latter  pro- 
cesses lead  to  an  opening  in  the  capsule  which  permits  the  entrance  and 
growth  of  granulations  into  the  labyrinth  and  finally  in  some  cases  to 
destruction  of  the  entire  membranous  labyrinth.  These  are  the  more 
frequent  conditions,  besides  which  we  have  empyema  of  the  saccus 
enclolymphaticus,  described  by  Koerner  and  others. 

We  will  not  enter  into  a  discussion  of  the  pathology  of  these  various 
lesions,  concerning  which  the  reader  is  referred  to  the  works  of 
Koemer,  Hinsberg,  Freytag,  Heine,  Neumann,  Alexander,  Ruttin  and 
others.  We  shall  discuss  rather  the  symptomatology  and  diagnosis. 

We  may  conveniently  divide  the  circumscribed  lesions  of  the  laby- 
rinth, according  to  their  location,  into  those  involving  the  cochlea  and 
those  involving  the  nonacoustic  labyrinth  according  to  the  symptoms 
and  reactibility  of  the  part  involved,  into  the  irritative  and  destructive. 


4_>  DIFFERENTIAL  DIAGNOSIS. 

Irritative  circumscribed  lesions  may,  under  'favorable  treatment,  re- 
main circumscribed  or  may  (rarely)  entirely  disappear;  however,  when 
neglected  the  irritative  processes  usually  becomes  a  circumscribed 
destructive  or  diffuse  destructive  process  of  the  labyrinth. 

From  the  above  it  is  readily  seen  that  we  may,  therefore,  have : 

i. — Circumscribed  irritative  lesion  of  the  cochlea. 

ii. — Circumscribed  destructive  lesion  of  the  cochlea. 

in. — Circumscribed  irritative  lesion  of  the  nonacoustic  labyrinth 
(vestibule  or  semicircular  canals). 

iv. — Circumscribed  destructive  lesion  of  the  nonacoustic  labyrinth 
(vestibule  or  semicircular  canals). 

It  should  not  be  a  difficult  task  to  differentiate  these  four  conditions 
from  each  other  and  from  labyrinth  suppuration. 

I,  B,  i. — CIRCUMSCRIBED  IRRITATIVE  LESION  OF  THE  COCHLEA  may 
show  most  or  all  of  the  following  characteristics : — 

By  Otoscopic  examination : 

(a)  Polyps  or  granulations  on  the  promontory,  or  exposed  bone  as 
determined  by  the  use  of  the  probe,  with  or  without  associated  choles- 
teatoma. 

Clinically  : 

(b)  Tinnitis. 

(c)  Marked  impairment  of  hearing  for  all  tones  if  the  entire  cochlea 
is  involved,  or  more  especially  the  high  tones  if  the  lower  cochlear 
whorl  alone  is  involved. 

(d)  Bone  conduction  shortened   (characteristic  for  all  internal  ear 
conditions). 

(e)  Very    positive    Gelle;   that   is   to   say,    with   compression   of 
air  in  the  external  canal  the  bone  conduction  is  shortened  very  much 
out  of  proportion  to  the  normal  (a  condition  opposite  to  that  found  in 
otosclerosis). 

(f)  Rarely  scotoma,  elicited  by  examination  with  Bezold's  continu- 
ous chain  of  forks. 

(g)  Absence  of  symptoms  from  the  vestibular  apparatus  with  quite 
normal  reactions  to  the  caloric,  turning  and  galvanic  tests. 

I,  B,  ii. — CIRCUMSCRIBED  DESTRUCTIVE  LESIONS  OF  THE  COCHLEA 
show  by  otoscopic  examination  :— 

(a)  Same  as  in  condition  I,  in  addition  perhaps  roughened  bone,, 
small  sequestra  or  fistula  in  the  region  of  the  promontory. 


LABYRINTH  PAPERS.  43 

Clinically : 

(b)  Absolute  deafness  for  some  or  all  tones,  depending  upon  the 
extent  of  the  lesion. 

(c)  Bone  conduction  very  much  shortened. 

(d)  Gelle,  /.  c.,  compression  and    aspiration    produces    no    effect 
upon  the  already  very  short  bone  conduction. 

(e)  Xo  symptoms  or  signs  from  the  vestibular  apparatus. 

I,  B,  in. — CIRCUMSCRIBED  IRRITATIVE  LESION  OF  THE  NONACOUSTIC 
LABYRINTH.  As  previously  stated  the  favorite  location  of  this  lesion 
is  the  horizontal  semicircular  canal  or  the  region  of  the  oval  window. 
The  otoscopic  examination  may  reveal  polyps  or  granulations,  with  or 
without  involvement  of  the  bone  in  the  antrum  or  attic-antrum  region. 
Clinically  the  symptoms  are : 

(a)  Vestibular  vertigo  with  its  accompanying  phenomena,  nausea 
and  vomiting,  depending  upon  the  intensity  of  the  vertigo. 

(b)  Spontaneous  nystagmus  toward  the  diseased  side.     Horizontal 
if  the  horizontal  semicircular  canal  is  the  seat  of  the  irritation ;  rotatory, 
if  the  region  of  the  oval  window  is  the  seat  of  the  irritation.     The 
m  stagmus  is  pronounced  during  the  attacks  of  vertigo  but  evident  also- 
between  attacks. 

(c)  Increased  reaction  of  the  nonacoustic  labyrinth,  especially  to 
turning  and  galvanism.    The  after-nystagmus  to  the  diseased  side  may 
last  from  35  to  100  seconds,  while  the  after-nystagmus  to  the  well  side 
remains   approximately  normal   or  but   slightly   increased,   20  to   25 
seconds. 

The  galvanic  reaction  shows  nystagmus  to  the  diseased  side,  when 
(he  kathode  is  to  the  diseased  ear,  with  a  much  weaker  current  than  is 
required  to  produce  a  nystagmus  to  the  well  side  when  the  kathode  is 
applied  to  the  well  ear.  In  making  the  galvanic  test  it  is  well  to  have 
the  patient  look  straight  ahead,  since  in  this  position  the  spontaneous 
nystagmus,  which  may  be  present  when  the  patient  looks  to  the  sides, 
is  perceptibly  diminished.  In  exceptional  cases  only  does  the  nystag- 
mus persist  when  the  patient  looks  straight  ahead. 

The  caloric  reaction  test  is  purely  a  qualitative  test  and  has  no  value 
in  determining  the  degree  of  irritability  of  the  labyritnh  in  any 
ca<c :  however,  it  plays  an  important  role  in  the  diagnosis  of  the 
next  (iv)  class  of  cases. 

(d)  Compression  and  aspiration  nystagmus;  also  known  by  some 


44  DIFFERENTIAL  DIAGNOSIS. 

writers  as  the  fistula  symptom  (Barany).  This  symptom,  when  pres- 
ent, is  a  symptom  of  importance.  If  the  lesion  is  in  the  horizontal 
semicircular  canal,  we  have  by  compression,  a  horizontal  nystagmus 
to  the  same  side,  and  by  aspiration  horizontal  nystagmus  to  the  opposite 
side.  If  the  lesion  is  in  the  region  of  the  oval  window  or  the  vestibule, 
we  have  by  compression  rotatory  nystagmus  to  the  opposite  side,  and 
by  aspiration  rotatory  nystagmus  to  the  same  side.  We  also  obtain 
this  latter  (rotatory)  form  of  compression  and  aspiration  nystagmus 
in  cases  of  dislocation  of  the  stapes  plate,  so  long  as  the  labyrinth  re- 
mains reactive. 

(e)  Acoustic  symptoms,  other  than  those  belonging  to  the  middle 
ear  suppuration,  are  negative. 

I,  B,  iv. — CIRCUMSCRIBED  DESTRUCTIVE  LESION  OF  THE  NONACOUSTIC 
LABYRINTH  presents  the  same  general  otoscopic  picture  as  in  condition 
in.  besides  the  following  clinical  signs : 

(a)  Vestibular  vertigo,  with  or  without  nausea  and  vomiting,  ac- 
cording to  the  stage  of  the  process.    In  the  early  stages  the  vertigo  is 
considerably  more  intense  than  in  condition  in. 

(b)  Nystagmus,  horizontal  or  rotatory,  according  to  the  location 
and  extent  of  the  process,  but  always  more  marked  to  the  well  side 
(similar  to  that  met  with  in  labyrinth  suppuration  and  opposite  to  that 
met  in  irritative  lesions  of  the  static  labyrinth). 

(c)  More  or  less  positive  disturbance  of  equilibrium,  similar  to  that 
found  in  labyrinth  suppuration  (the  early  and  the  late  forms). 

(d)  Caloric  examinaiton  is  negative  when  the  entire  nonacoustic 
labyrinth  is  destroyed ;  partially  negative*  when  a  part  only  is  destroy- 
ed.    Relatively  the  same  may  be  said  for  the  turning  and  galvanic  re- 
actions. 

The  differentiation  of  the  different  •  forms  of  circumscribed  laby- 
rinthitis  from  each  other  and  from  labyrinth  suppuration  should  not 


*I  say  "partially  negative"  wittingly.  As  an  illustration— it  was  my  good 
fortune  to  be  able  to  make  repeated  examinations  of  a  case  with  an  operative 
injury  of  the  horizontal  semicircular  canal ;  immediately  after  the  injury  the 
patient  exhibited  all  the  signs  and  symptoms  of  acute  destructive  lesion  of  the 
static  labyrinth  with  negative  reactions,  due  no  doubt  to  loss  of  endo-  and  peri- 
lymph.  After  ten  days  or  two  weeks  the  reactions  began  to  reappear;  though 
diminished,  they  were  positive.  Reactions  from  the  horizontal  semicircular  canal 
remained  negative  while  the  reactions  from  the  vertical  canals  remained  positive 
by  the  caloric  examination  as  well  as  by  turning  and  galvanism. 


LABYRINTH  PAPERS.  -!5 

be  difficult.  The  differentiation  of  the  irritative  from  the  destructive 
form  should  be  quite  easy.  There  is  but  one  of  the  four  conditions 
which  might  be  confounded  with  labyrinth  suppuration  and  that  is  the 
circumscribed  destructive  lesions  of  the  static  labyrinth,  and  then  only 
in  those  very  old  chronic  cases  where  the  hearing  has  been  previously 
so  greatly  impaired  that  it  may  be  mistaken  for  absolute  deafness.  In 
other  words  a  case  where  through  long  continued  suppuration,  a  grad- 
ual destructive  process  of  the  cochlea  had  taken  place,  when  suddenly 
the  patient  develops  an  acute  destructive  lesion  of  the  static  labyrinth. 
Such  cases  are  not  so  rare.  The  question  is  decided  by  the  hearing 
tests ;  the  slightest  rests  of  hearing  excludes  diffuse  labyrinth  suppura- 
tion. 

II.    AFFECTIONS    OF   THE   BONY    LABYRINTH    SECONDARY    TO    MIDDLE   EAR 

SUPPURATION. 

These  are  usually  erosions,  fistulse,  small  areas  of  necrosis,  with  or 
without  granulations  and  frequently  associated  with  cholesteatoma  or 
tubercular  granulations.  Any  part  of  the  labyrinth  capsule  may  be  in- 
volved, but  more  often  the  external  wall.  In  cases  where  there  is  a 
necrotic  piece  of  the  capsule  not  yet  loosened  from  the  surrounding 
bone  there  may  be  an  absence  of  symptoms  until  by  manipulation  with 
instruments  or  by  pressure  of  water  syringed  into  the  middle  ear,  the 
necrotic  piece  is  pressed  inward  against  the  membranous  labyrinth 
when  the  patient,  if  the  necrotic  bone  be  in  the  region  of  the  static  laby- 
rinth, experiences  sudden  vertigo  with  its  accompanying  phenomena; 
when  in  the  region  of  the  promontory,  sudden  tinnitus  with  or  without 
deafness.*  Similar  symptoms  may  be  experienced  at  any  time  during 
the  attempt  at  extraction  of  polyps.  The  tearing  away  of  a  polyp  with 
a  snare  may  bring  with  it  a  small  necrotic  portion  of  the  labyrinth  cap- 
sule (such  a  case  having  been  witnessed  by  the  writer). 

Affections  of  the  bony  labyrinth  are  sooner  or  later  associated  with 
some  affection  of  the  membranous  labyrinth,  either  circumscribed  or 
diffuse  (see  above). 

The  affections  of  the  labyrinth  capsule  present  three  stages :  first, 
— Invasion  Stage,  before  symptoms  are  evident  and  the  membranous 


*Deafness  with  tinnitus  would  seem  rather  paradoxical,  nevertheless  their  co- 
existence is  not  so  rare  in  acquired  deafness.  (See  Dr.  Alice  V.  Mackenzie 
"Galvan.  Akustikus  React."  Wiener  Klin.  Wochenschr.,  1908,  Nr.  II.) 


46  DIFFERENTIAL  DI.iGXOSIS. 

labyrinth  is  intact  and  the  reactions  are  normal.  Second. — Manifest 
Stage;  symptoms  of  irritation  of  the  membranous  labyrinth  are  evi- 
dent. Third, — Final  Stage;  may  be  limitation  of  the  process  with 
resolution  or  may  be  the  spreading  of  infection  to  the  entire  mem- 
branous labyrinth  (labyrinth  suppuration)  or  beyond  the  labyrinth  to 
the  meninges  and  brain. 

Of  the  different  affections  of  the  labyrinth  capsule,  fistula  of  the 
horizontal  semicircular  canal  at  the  prominence  is  the  most  fn-quent 
and  easiest  recognized,  and  for  this  reason  we  shall  give  it  some  special 
attention  (see  Neumann.  "Uber  einen  Fall  zircumscripter  Laby- 
rintherkrankung,"  Oct.,  1907,  Monatschr.  f.  Ohrcnhciik). 

Fistula  of  the  prominence  of  the  horizontal  semicircular  canal  is  gen- 
erally but  not  invariably  due  to  erosion  from  cholesUatoma.  The 
fistula  in  its  earliest  stage  may,  as  previously  stated,  be  free  of  symp- 
toms because  of  a  quite  normal  membranous  labyrinth.  In  the  later 
stages  the  membranous  labyrinth  may  be  considererably  involved,  even 
to  the  extent  of  destruction,  evident  by  negative  reactions. 

A  characteristic  sign  of  fistula,  so  long  as  the  membranous  laby- 
rinth is  intact,  is  the  so-called  fistula  symptom  of  Barany,  better  known 
by  other  writers  as  the  compression  and  aspiration  nystagmus.  Alex- 
ander and  Lasalle,  "Ueber  den  durch  Luft  Druckveraenderungen  aus 
loesbaren  Nystagmus  und  das  Fistel  Symptom,"  Wiener  Klin.  Rundsch., 
1908).  This  symptom  is  negative  in  late  cases  after  the  membranous 
labyrinth  is  destroyed.  The  production  of  this  nystagmus  is  really 
nothing  more  than  the  clinical  application  of  Ewald's  experiment  made 
upon  the  semicircular  canals  of  animals.  (See  Barany  on  "Physiologic 
uncl^  Pathologic  des  Bogeng.  Apparat.")  The  examination  is  made 
with  a  Gelle  balloon  or  ordinary  Politzer  bag  fitted  with  rubber  tubing, 
on  the  end  of  which  is  attached  a  perforated  spherical  or  olive~pointed 
hard  rubber  tip.  The  tip  is  fitted  into  the  external  canal  firmly  enough 
to  prevent  the  escape  of  air.  Compression  of  the  balloon  causes  in- 
creased air  pressure  In  the  canal  and  middle  ear  cavity.  A  positive 
reaction  is  denoted  by^  a  horizontal  nystagmus  to  the  same  side  by  com- 
pression and  to  the  opposite  side  by  aspiration. 

This  symptom  is  positive  in  the  first  and  second  stages  and  negative 
in  the  final  stage.  Aside  from  this  symptom  the  first  stage  of  fistula 
presents  negative  symptoms  and  si] 

The  second  stage  will  show  this  sign  plus  the  signs  of  circumscribed 


LABYRINTH  PAPERS.  -17 

irritative  lesion  of  the  labyrinth  (see  above).  In  the  third  stage,  the 
•compression  and  aspiration  nystagmus  is  negative  and  the  other  signs 
and  symptoms  are  those  of  circumscribed  destructive  lesion  of  the 
labyrinth,  or  if  there  has  been  a  spreading  of  infection  then  we  have  the 
symptoms  and  signs  of  diffuse  destruction  (labyrinth  suppuration). 

III.    AFFECTION  OF  THE  PERILABYRINTHINE  SPACES. 

*PERILABYKI.\TIIITIS  is  a  process  which  involves  the  perilabyrinthine 
tissue  and  is  favored  by  a  pneumatic  condition  of  the  cells  in  the  pyramid 
surrounding  the  labyrinth  capsule.  These  cells  are  in  direct  communi- 
cation with  and  form  a  part  .of  the  mastoid  cells.  Severe  constitutional 
disturbances  and  especially  diabetes  favor  the  extension  of  mastoiditis 
into  these  perilabyrinthine  mastoid  cells  with  resulting  partial  or  com- 
plete sequestration  of  the  bony  labyrinth.  Perilabyrinthitis  may  be  as- 
sociated with  acute  or  chronic  suppuration  of  the  middle  ear.  The 
secondary  dangers,  meningitis  and  brain  abscess,  are  not  so  great  in 
this  as  in  labyrinth  suppuration. 

The  symptoms  and  signs  of  perilabyrinthitis  are  very  like  those  of 
labyrinth  suppuration ;  however,  there  are  points  of  difference  which 
make  it  possible  for  us  to  make  a  differential  diagnosis  between  these 
two  processes  and  are  as  follows : 

LABYRINTH  SUPPURATION.  PERILABYRINTHITIS. 

I. — More  often  secondary  to  i. — More  often  secondary  to 

chronic  middle  ear  suppuration.  acute  middle  ear  suppuration. 

2. — The  process  begins  suddenly.  2. — The  process  begins  more 

gradually. 

3. — May  be,  but  not  necessarily,  as-  3. — Always  associated  with 

sociated  with  mastoiditis.  mastoiditis. 

4. — Otoscopic  findings  not  char-  4. — Otoscopic  findings  in  ad- 

acteristic.  vanced  cases  always  show 

necrotic  bone. 

5- — Associate  facial  palsy  the  ex-  5. — Facial  palsy  the  rule,  since 

ception,  and  when  present  has  the  facial  canal  is  surrounded 

no  direct  connection  with  laby-  by  the  same  perilabyrinthine 

rinth  suppuration.  cells  as  is  the  labyrinth  itself. 


*I  prefer  the  term  Perilabyrinthitis  to  that  of  Paralabyrinthitis  used  by  most 
of  the  German  authors. 


DIFFERENTIAL  DIAGNOSIS. 


6. — As  a  rule,  associated  menin- 
geal  irritation  or  meningitis  or 
other  intracranial  complications. 

7. — No  direct  relationship  to  sys- 
temic or  constitutional  diseases. 

8. — The  Weber  test  shows  laterali- 
zation  to  the  well  ear. 


6. — Intracranial 
the  exception. 


•complications 


7. — Frequent  association  of  sys- 
temic or  constitutional  dis- 
eases. 

8. — According  to  Neumann, 
Weber  lateralized  to  the  dis- 
eased car.  However,  with 
writer,  this  is  still  an  open 
question. 


DIFFERENTIATION  OF  LABYRINTH  SUPPURATION  FROM 
CEREBELLAR  ABSCESS. 

THE  preceding  paper  upon  the  subject  of  Differential  Diagno- 
sis dealt  only  with  the  surgical  diseases  of  the  labyrinth 
secondary  to  middle  ear  suppuration,  the  writer  having  re- 
served this,  a  separate  paper,  for  the  differentiation  of  labyrinth  sup- 
puration from  cerebellar  abscess.  Before  taking  up  the  differentiation 
it  will  be  well  first  to  go  briefly  over  the  subject  of  cerebellar  abscess, 
just  as  we  have  in  our  first  paper  gone  briefly  over  the  subject  of 
labyrinth  suppuration. 

To  begin  with,  let  us  recall  the  facts,  first,  that  the  physiology  of  the 
cerebellum  is  still  a  somewhat  unsettled  problem ;  secondly,  that  the 
symptomatology  of  cerebellar  diseases  (including  abscess)  is  very 
variable.  In  looking  over  the  literature  upon  the  subject  of  cere- 
bellar abscess,  one  is  impressed  with  the  disagreement  of  authors,, 
no  two  of  them  agreeing  upon  any  set  of  pathognomonic  or  even  car- 
dinal signs.  The  nearest  approach  to  such  signs  is  to  be  found  under 
the  heading,  "Zerebellar  Nystagmus,"  in  Neumann's  work  upon  this 
subject,  "Der  Otitische  Kleinhirn  Abscess,"  1907.  The  above  facts  are 
a  sufficient  reason  for  our  inability  in  some  cases  to  make  exact 
diagnoses. 

The  cause  of  cerebellar  abscess  is  suppuration  of  the  middle  ear, 
according  to  Oppenheim  in  almost  one-half  the  cases,  and  according 
to  Ghon  (in  a  paper  read  before  the  American  Medical  Association  of 
Vienna,  in  1907)  in  about  two-thirds  of  the  cases. 

Otitic  cerebellar  abscess  occurs  somewhat  less  than  half  as  frequently 
as  otitic  temporal-lobe  abscess,  or  as  198  is  to  428  (Heimann,  A.  f.  O., 
bd.  66  and  67). 

Cerebellar  abscesses  vary  in  size  from  that  of  a  hazelnut  to  that  of 
a  hen's  egg  and  larger.  They  are  generally  single,  but  may  be  multiple ; 
however,  Neumann  believes  that  the  apparently  multiple  abscesses  are 
nothing  more  than  so  many  extensions  of  a  single  abscess.  There  is 
no  direct  proportion  between  the  size  of  the  abscess  and  the  symptoms 
it  may  produce. 

Cerebellar  abscess  may  run  an  acute  or  chronic  course.  The  course 
is  dependent  upon  the  virulence  of  the  infecting  micro-organism  and 
4 


50      LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

the  presence  or  absence  of  a  pyogenic  membrane.  The  diplococcus  of 
Fraenkel-Weichselbaum  is  prone  to  form  a  capsule,  while  the  anaerobic 
bacteria  do  not.  The  latter  tend  also  to  the  formation  of  very  fetid 
smelling  abscesses  (Ghon,  Zcntralblatt  f.  Bakt.,  41,  1906). 

Otitic  cerebellar  abscess  may  result  from  acute  or  chronic  middle  ear 
suppuration.     From  the  combined  statistics  of  Okada,  Heimann  and 


Figure  I.  Half  schematic  horizontal  cut  through  the  right  ear,  showing  the 
routes  of  infection  from  the  middle  ear  to  the  posterior  skull  fossa.  (By  Alex- 
ander). Almost  normal  six.e. 

Neumann  in  869  cases,  82  per  cent,  resulted  from  chronic  and  18  per 
cent,  from  acute  middle  ear  suppuration. 

The  routes  of  infection,  according  to  Politzer,  in  the  order  of  their 
frequency  are:   I,  labyrinth  (in  cases  following  labyrinth  suppuration)  ; 

2,  posterior  surface  of  the  pyramid  (in  cases  of  caries  and  necrosis)  ; 

3,  lateral  sinus  wall  (in  case  of  sinus  phlebitis)  ;  4,  median  wall  of  the 
mastoid.     According  to  Alexander,  the  route  of  infection  to  the  pos- 
terior fossa  is  thru  preformed  and  nonprefornu-d  i^ays.    To  better  show 
these  various  routes  the  reader  is  referred  to  figure  i,  half  schematic, 


LABYRINTH  PAPERS.  51 

by  Alexander  in  Professor  Hochenegg's  "Lehrbuch  der  Chir.  und 
Open,"  1906,  and  more  recently  "Die  ohrenkrankheiten  im  Kindesalter 
1912  by  Alexander. 

The  preformed  ways  are  thru  the  labyrinth  along  the  nerve 
packet  of  the  canalis  auditorius  interna,  indicated  in  Fig.  I  by  the 
heavy  line  2 ;  along  the  facial  canal,  indicated  by  heavy  line  6 ;  along 
the  ductus  and  saccus  endolymphaticus,  indicated  by  heavy  line  7. 

The  nonpreformed  ways  are :  sinus  sigmoideus,  indicated  by 
line  i  ;  thru  the  cochlea,  indicated  by  line  3,  or  thru  the  semicircular 
canals,  indicated  by  line  4 ;  thru  the  median  wall  of  the  mastoid  behind 
the  sinus,  indicated  by  line  5.  Infection  of  the  posterior  fossa  may  also 
take  place  thru  a  combination  of  two  or  more  of  these  ways. 

Infections  along  preformed  ways,  with  the  exception  of  the  ductus 
and  saccus  endolymphaticus  (Alexander,  Jansen,  Neumann),  are 
more  prone  to  produce  meningitis  (diffuse  or  circumscribed) than  in- 
fection thru  nonpreformed  ways.  On  the  other  hand,  infections  thru 
the  ductus  and  saccus  endolymphaticus  and  the  nonpreformed  ways 
are  more  prone  to  produce  extradural  and  cerebellar  abscesses.  It 
must  not  be  forgotten  that  there  are  exceptions  to  these  rules. 

Otitic  cerebellar  abscess  is  more  liable  than  not  to  be  associated  with 
other  complications,  which  accounts  for  the  variability  and  confusion 
of  the  symptoms  already  mentioned.  These  complications  are : 

1.  Sinus  phlebitis.     Found  especially  in  cases  of  cerebellar 
abscess  following  acute  middle  ear  suppuration;  8  out  of  19  cases,  or 
40  per  cent.,  according  to  Neumann. 

2.  Extradural  abscess.    Politzer  and  others  have  found  this 
complication  especially  frequent  in  cases  of  cerebellar  abscess  following 
•chronic  middle  ear  suppuration.   The  dura  is  thickened  and  adherent, 
and  frequently  there  is  a  communicating  fistula  between  the  extradural 
and  cerebellar  abscesses.     Koerner  fouud  this  fistulous  communication 
in  42  per  cent,  of  otitic  brain  abscesses  irrespective  of  location. 

3.  Subdural    abscess    (Heine)   found  in  acute  cases;  how- 
ever, the  percentage  is  small. 

4.  Labyrinth  suppuration  is  found  in  more  than  one-half 
of  the  cases  of  cerebellar  abscesses  following  chronic  middle  ear  sup- 
puration (combined  estimate  of  several  authors),  but  is  never  found  in 
acute  cases  (Neumann).     Labyrinth  suppuration  resulting  from  acute 
middle  ear  suppuration  is  more  apt  to  be  followed  by  meningitis. 

5.  Circumscribed       pachyleptomeningitis       and 
serous  meningitis  (Alexander,  Neumann,  Koerner). 


52      LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

I  have  not  included,  in  the  above  grouping,  diffuse  suppurative  men- 
ingitis, since  this  is  rather  the  result  than  an  associated  complication 
of  cerebellar  abscess. 

Heimann  (A.  f.  O.,  66,  251)  in  a  conservative  statement  claims  that 
almost  50  per  cent,  of  otitic  cerebellar  abscesses  are  uncomplicated. 
This  may  be  taken  as  a  negative  statement,  acknowledging  that  some- 
what more  than  50  per  cent,  are  complicated.  Most  authors  accept  even 
larger  figures. 

Cerebellar  abscesses  present  four  stages:  i,  initial  stage;  2,  latent 
stage;  3,  manifest  stage;  4,  terminal  stage. 

i.  Initial  stage.  This  is  the  stage  of  primary  infection,  which 
takes  place  rather  abruptly  and  is  accompanied  by  a  change  in  char- 


Figures.     Posterior  surface  of  the  temporal  bone.     (By  Alexander).     Almost 
normal  size. 

acter  or  amount  of  secretion  from  the  middle  ear  (Alexander)  ;  initial 
chill  with,  as  a  rule,  not  very  high  fever;  vertigo,  rather  inconstant; 
headache,  especially  occipital  but  may  be  frontal ;  retroauricular  tender- 
ness and  general  malaise.  These  symptoms  are  more  or  less  pro- 
nounced, altho  frequently  forgotten  by  the  patient,  who  may  present 
himself  for  the  first  time  during  the  manifest  stage.  The  symptoms  of 
the  initial  stage  are  frequently  attributed  to  some  obscure  intercurrent, 
so  called  bilious,  attack.  The  initial  stage  is  brief  and  subsides  after  a 
few  days,  when  the  condition  goes  over  into  a  more  or  less  prolonged 
latent  stage. 

2.    Latent  stage.    This  is  the  intervening  stage  before  the  third 
or  manifest  stage.     During  the  latent  stage  there  is  more  or  less  dull 


LABYRINTH  PAPERS.  53 

headache,  localized  retroauricular  tenderness ;  in  addition,  according  to 
Politzer,  moderate  amount  of  prostration,  apathy,  pallor  of  the  face, 
loss  of  body  weight,  loss  of  appetite ;  according  to  Oppenheim,  moder- 
ate elevation  of  temperature,  occasional  epileptiform  or  hysterical  fits, 
psychic  disturbances,  apathy  and  melancholia.  These  symptoms,  ac- 
cording to  the  opinion  of  the  writer,  are  not  especially  indicative  of 
cerebellar  abscess,  however  they  may  suggest  it. 

To  the  symptoms  just  enumerated  there  may  be  in  addition  symp- 
toms of  labyrinth  suppuration  or  extradural  abscess  when  either  of 
these  complications  are  found  associated  with  chronic  middle  ear  sup- 
puration, or  the  symptoms  of  sinus  phlebitis  when  this  complication  is 
found  associated  with  acute  middle  ear  suppuration. 

Referring  to  complicating  extradural  abscess,  the  headache  and  cir- 
cumscribed tenderness  may  be  identical  with  that  found  in  cerebellar 
abscess.  According  to  Alexander,  the  location  of  this  tenderness  is  4 
or  5  cm.  behind  the  auricle,  and  the  spot  is  so  circumscribed  that  it  may 
be  covered  with  the  ball  of  the  thumb.  Alexander  (Lehrbuch  der 
Ghir.  und  Oper.,  Prof.  Hochenegg)  advises  prompt  operation  for  all 
cases  of  extradural  abscess,  upon  the  ground  that  if  not  operated  there 
is  great  danger  of  meningitis,  sinus  phlebitis  or  brain  abscess  resulting. 

Since  it  is  recognized  that  a  fair  percentage  of  cerebellar  abscesses 
follow  extradural  abscess  and  labyrinth  suppuration,  it  is  logi- 
cal treatment  to  expose  the  dura  and  favor  drainage  in  case 
of  extradural  abscess  and  to  remove  a  sufficient  part  of  the 
labyrinth  for  the  same  purpose  in  case  of  labyrinth  suppura- 
tion before  the  cerebellar  abscess  or  other  intracranial  com- 
plications have  had  time  to  develop.  The  efficiency  of  this 
form  of  radical  treatment  has  been  already  demonstrated  by  the 
steady  falling  off  in  the  number  of  cases  of  cerebellar  abscess  in  the 
Politzer  klinik  during  the  last  few  years,  where  this  line  of  treatment 
has  been  carried  out.  Alexander  claims  the  same  results  for  the  Poly- 
klinik  in  Vienna. 

The  latent  stage  may  last  from  a  few  weeks  to  several  months,  and 
even  longer  (Oppenheim,  MacEwen). 

3.  Manifest  stage.  This  stage  represents  that  of  the  fully 
developed  abscess.  In  this  stage  the  symptoms  are  pronounced.  The 
headache  (occipital  or  frontal),  occipital  tenderness,  vertigo,  vomiting, 
lassitude,  apathy,  characteristic  pallor  of  the  face,  inform  us  that  the 
patient  is  suffering  some  severe  intracranial  complication,  possibly 


54      LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

cerebellar  abscess.  This  condition  lasts,  as  a  rule,  a  few  weeks  or 
longer,  in  exceptional  cases  but  a  few  days  only ;  during  this  time  the 
patient  diminishes  rapidly  in  body  weight,  even  out  of  proportion  to  the 
diminution  of  nourishment  taken.  This  stage  passes  more  or  less 
abruptly  over  into  the  terminal  stage. 

4.  Terminal  stage.  This  stage  is  generally  brief  and  almost 
invariably  results  fatally. 

In  exceptional  cases  spontaneous  recovery  has  been  observed  thru 
rupture  of  the  abscess  externally  into  the  middle  ear  cavity  (Brims, 
Huguenin,  Wilde,  Pollak  and  others)  ;  also  thru  resorption  of  the  con- 
tents of  abscess  (Braun,  Brieger,  Rheinhard)  ;  however,  Politzer  be- 
lieves that  most  of  these  cases  were  rather  cases  of  extradural  abscess. 

The  terminal  stage  of  cerebellar  abscess  is  due  more  frequently  to 
rupture  of  the  abscess  into  the  leptomeningeal  space  or  the  ventricles 
with  resulting  diffuse  suppurative  meningitis  in  the  first  instance  or 
acute  hydrocephalus  from  closure  of  the  foramen  Magendi  with  the 
products  of  the  abscess  in  the  second  instance,  less  frequently  to  sud- 
den increase  of  volume  of  the  abscess  causing  pressure  upon  the  me- 
dulla oblongata,  and  thereby  death  from  sudden  paralysis  of  respira- 
tion, while  the  heart  tends  to  continued  action  for  hours,  especially 
where  the  respiration  has  been  artificially  continued.  (Barker,  British 
Medical  Jvurnal,  1902;  Fliess,  Dentsch.  Med.  IVocJicnschr.,  1903.) 
Knapp  reports  a  case  of  continued  heart  action  for  forty-eight  hours 
after  respiration  had  been  artificially  continued. 

Other,  but  still  less  frequent,  causes  of  death  are  toxic  coma,  en- 
cephalitis serosa  in  the  area  surrounding  the  abscess,  sinus  phlebitis 
(pyemia)  and  pneumonia. 

SYMPTOMATOLOGY. 

Takabataka  (Z.  f.  O.,  46,  236)  has  demonstrated  that  there  is  a  lack 
of  relationship  between  the  size  of  the  abscess  and  the  symptoms  it 
may  produce. 

The  symptoms  of  cerebellar  abscess  are  those  belonging  (i)  to  the 
primary  middle  ear  supuration ;  (2)  to  the  cerebellum  itself  (focal 
symptoms)  ;  (3)  to  neighboring  or  distant  parts  (so  called  "durch  fern- 
wirkunk"  symptoms  of  the  German  authors),  the  medulla,  pons,  cere- 
bral hemispheres,  intracranial  nerve  roots  of  the  posterior  fossa 
(Koerner)  and  the  upper  part  of  the  cervical  cord  (MacEwen)  ;  (4) 
to  increased  intracranial  pressure;  (5)  to  associated  complications,  es- 
pecially labyrinth  suppuration,  extradural  abscess,  encephalitis,  sinus 


LABYRINTH  PAPERS.  55 

phlebitis  and  meningitis;  and  (6)  to  toxic  origin  (Neumann) 
due  to  the  absorption  of  the  products  of  the  abscess.  It  is  often 
difficult  to  isolate  a  symptom  and  tell  positively  to  which  of  these 
it  is  due.  Accordingly  I  shall  not  make  any  attempt  at  classification  of 
the  symptoms  as  Koerner,  Neumann  and  a  few  others  have  done, 
but  shall  content  myself  rather  with  the  enumeration  of  the  symptoms 
as  found  in  a  case  of  cerebellar  abscess.  Many  of  these  symptoms  are 
accepted  by  most  authors  and  denied  by  others.  I  shall  classify  the 
symptoms  under  three  headings: 

I.     The  more  frequent  symptoms. 
II.     The  less  frequent  symptoms. 

III.     The  special  symptoms. 

Wherever  it  is  possible,  I  shall  refer  to  their  relative  value  and 
possible  origin. 

I.       THE  MORE  FREQUENT  SYMPTOMS. 

These  together  with  the  special  symptoms  are  the  more  important 
symptoms  found  in  cerebellar  abscess.    They  are: 

1.  Headache.   Occipital  headache  upon  the  affected  side  is  the  most 
characteristic  and  typical  headache  of  cerebellar  abscess.     Less  fre- 
quently there  is  frontal  headache.     Krause  explains  the  frontal  head- 
ache as  reflex  from  the  ramus  recurrens  Arnoldi,  branch  of  the  fifth 
nerve  (which  supplies  the  tentorium)  to  the  ramus  meningeus  anterior 
which  supplies  the  dura  of  the  anterior  fossa.     Very  rarely  or  never 
is  there  parietal  headache  present  as  in  case  of  temporal  lobe  abscess. 

2.  Pressure  or  percussion  tenderness  in  the  occipital  region  of  the 
affected  side.     This  tenderness  is  more  often  circumscribed,  but  may 
be  diffuse.     This  symptom  as  well  as  the  preceding   (occipital  head- 
ache) is  no  more  characteristic  for  cerebellar  than  for  extradural  ab- 
scess, as  pointed  out  elsewhere. 

3.  Rigidity  of  the  neck,  more  especially  the  nape,  is  frequently  com- 
bined with  inclination  of  the  head  to  the  diseased  side.    This  symptom 
is  held  by  Alexander  and  Von  Beck  as  a  very  important  one.     Neu- 
mann, on  the  contrary,  believes  this  symptom  is  not  characteristic  for 
uncomplicated   cerebellar   abscess.     A   characteristic    feature   of  this 
symptom  is  that  the  patient  supports  the  head  with  the  hands  during 
attempts  at  movements.    The  frequency  of  this  symptom  in  cerebellar 
abscess  has  been  observed  by  the  writer. 

4.  Homolateral  hemiparesis  and  hemianesthesia  in  contradistinction 


56      LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

to  the  contralateral  found  in  temporal  lobe  abscess.  In  a  case  of 
Uffenorde's  (A.  f.  O.  67,  179  and  189)  convulsions  in  the  arm  of  the 
same  side.  The  cause  of  the  homolateral  hemiparesis  is  ascribed  by 
some  authors  to  pressure  upon  the  opposite  pyramid  at  the  foramen 
magnum,  while  others  (Pineles,  Monokow)  believe  it  is  purely  a  focal 
symptom  from  the  cerebellum.  The  writer  inclines  to  the  latter  ex- 
planation as  the  more  possible  and  logical  one. 

5.  Cerebellar  ataxia,  observed  by  innumerable  authors,  seems  to  be 
purely  a  focal  symptom   (Nothnagel  ascribed  its  origin  to  pathologic 
causes  located  in  the  worm  of  the  cerebellum),  especially  noticeable  in 
the  extremities  of  the  affected  side.     The  trunk  muscles  are  also  fre- 
quently involved.     In  this  connection  Babinski  has  noted  a  peculiar 
phenomenon,  which  he  terms  "asynergie  cerebelleuse."    This  phenome- 
non manifests  itself  when  the  patient  attempts  to  walk:  the  legs  pro- 
ceed forward  in  the  usual  manner  but  the  trunk  does  not  follow; 
remaining  behind,  giving  the  patient  a  peculiar  attitude.     This  nhe- 
nomenon  manifests  .itself  also  when  the  patient  attempts  to  walk  back- 
ward, the  relative  position  of  the  legs  and  trunk  assuming  the  reverse 
position  to  that  found  when  walking  forward:     Babinski  believes  the 
symptom  to  be  a  very  important  -one  in  cerebellar  abscess. 

6.  Optic  neuritis,  or  choked  disc,  is  found  more  frequently  in  cere- 
bellar abscess  (Politzer,  Hinsberg,  Koerner,  Neumann  and  others)  than 
in  temporal  lobe  abscess.     Zaufall  claims  that  he  never  failed  to  find 
some  fundus  changes  in  cerebral  complications  of  chronic  middle  ear 
suppuration ;  the  changes  however  were  often  very  slight.  These  changes 
include  unsharpness  of  the  disc,  overfilling  of  the  veins  and  increased 
tortuosity  of  the  vessels.     On  the  other  hand,  Jansen  (A.  f.  O.,  36), 
Koerner  (Z.  /.  O.,  23)  and  Bezold  (Handbuch  ges.  Augenheilk.,  von 
Graefe   Saemisch,    1903)    have   claimed   similar   changes    for    simple 
empyema  of  the  mastoid  cells,  which  cleared  up  promptly  after  simple 
mastoid  operation.    Notwithstanding,  the  concensus  of  opinion  is  that 
-neuritis  or  choked  disc  is  a  very  frequent  sign  of  cerebellar  abscess 

7.  Impairment  of  intellect   (slow  cerebration,  MacEwen)  together 
with  apathy,  somnolence,  stupor  and  finally  coma,  form  a  symptom 
group  quite  characteristic  for  cerebellar  abscess.    Alexander  lays  great 
stress  upon  the  somnolence.   The  slow  cerebration  may  be  manifested 
even  during  the  latent  stage,  while  somnolence  belongs  rather  to  the 
later  stage.     Neumann,  while  recognizing  these  as  important  symp- 
toms found  in  cerebellar  abscess,  places  them  among  those  produced  by 
the  effects  of  the  abscess  upon  more  distant  parts  of  the  brain. 


LABYRINTH  PAPERS.  57 

8.  Slowness  of  the  pulse  rate,  held  by  MacEwen  and  Barr  as  one  of 
the  most  important  signs  of  cerebellar  abscess,  the  pulse  rate  diminish- 
ing to    thiry  beats  per  minute  and  less.    Arythmia  of  the  pulse  (Neu- 
mann) is  quite  characteristic;  notwithstanding,  we  find  the  same  char- 
acter of  the  pulse  in  many  other  conditions  (encephalitis,  tumor  cere- 
bri,  etc.)  where  the  intracranial  pressure  is  greatly  increased. 

9.  Trophic  disturbances,  as  evidenced  by  rapid  loss  of  body  weight 
out  of  proportion  even  to  the  diminution  of  nourishment  taken,  as  a 
result  of  anorexia.    This  symptom  is  so  characteristic  and  frequent  that 
Okada  was  able  to  detect  it  in  37  of  his  40  cases. 

10.  Anarthria  and  dysarthria  (Fimmer,  dissertation,  Leipsic,  1905), 
supposed  to  be  the  result  of  pressure  of  the  abscess  or  the  effects  of 
the  toxins  upon  the  medulla  oblongata.     These  symptoms,  no  matter 
how    produced,   have    been    repeatedly    observed    in    association    \yith 
cerebellar  abscess,  and  the  writer  considers  them,  when  present,  as 
symptoms  of  relative  importance  in  cerebellar  abscess. 

II.       THE  LESS  FREQUENT  SYMPTOMS. 

Let  us  next  consider  symptoms  belonging  to  group  II.  These  symp- 
toms, tho  less  frequent  than  the  former,  can  hardly  be  considered  less 
important  since  they  have  been  observed  and  reported  by  equally  trust- 
worthy observers.  They  are : 

11.  Deviation  conjugee.     Xeumann  (der  Otit.  Kleinhirn  Abscess,  p. 
28)  observed  this  symptom  in  four  of  his  cases.     Relative  to  this  sign 
the  writer  wishes  to  note  that  it  is  not  necessarily  a  cortical  one,  but  in- 
stead is  a  reflex  in  a  comatose  patient  produced  by  any  irritation — in 
Deiter's  nucleus  or  in  the  posterior  longitudinal  bundle — which  would 
produce  nystagmus  in  a  conscious  patient.     This  deviation  represents 
but  one  phase  of  the  nystagmus,  observed  by  Barany,  the  writer  and 
others  in  patients  under  general  anesthesia,  who  in  a  wakeful  condi- 
tion show  nystagmus. 

To  illustrate :  If  a  patient  has  an  irritative  lesion  in  the  semicircular 
canals,  vestibular  nerve  or  Deiter's  nucleus  of  the  right  side,  he  will 
exhibit  a  rotatory  nystagmus  to  the  right  side.  The  nystagmus  is 
furthermore  rhythmic  and,  as  has  been  pointed  out,  is  composed  of 
a  rapid  movement  of  the  eyeballs  to  the  right  and  a  slow  movement  to 
the  left.  The  slow  movement  represents  the  vestibular  reflex,  while  the 
rapid  movement  represents  the  voluntary  cortical  act.  Should  the 
same  patient  be  put  under  a  general  anesthetic,  the  voluntary  cortical 
movement  is  suppressed  and  there  remains  but  the  reflex  movement 


58      LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

alone,  the  eyes  assuming  the  extreme  lateral  position  to  the  opposite 
(left)  side ;  in  other  words,  we  have  deviation  conjugee  to  the  side  op- 
posite the  irritation,  as  found  in  cases  of  cerebellar  abscess. 

I  agree  with  Neumann  that  the  sign,  when  present,  is  an  important 
positive  one,  and  furthermore  I  believe  the  sign  may  be  observed  more 
frequently  than  it  really  is  if  carefully  looked  for  in  all  cases. 

12.  Herpes  labialis,  observed  by  Schmiegelow  (Archives  Internal. 
de  Laryng.,  XIX,  337)  in  four  cases  out  of  nineteen  of  brain  abscess, 
irrespective  of  location.    Observed  also  by  Koerner  (Z.  /.  O.,  44)  and 
freely  quoted  by  others. 

13.  Homolateral  hypoglossus  paresis  observed  by  Uffenorde  (A.  f. 
0.,  67,  179). 

14.  Glycosuria,  observed  by  Frey  (Z.  /.  O.,  58,  171),  also  by  Grun- 
ert  and  MacEwen. 

15.  Retention  and  incontinence  of  urine  and  albuminuria  have  been 
observed  by  Brieger,  Oppenheim  and  MacEwen. 

The  symptoms  thus  far  considered  belong  more  or  less  distinctively 
to  cerebellar  abscess  and  not  to  labyrinth  suppuration.  The  presence 
or  absence  of  these  symptoms  are  important  ones  in  the  differential 
diagnosis. 

We  shall  next  consider  a  group  of  symptoms  (III.  Special  symp- 
toms) common  to  both  conditions,  symptoms  which  are  responsible  for 
the  resemblance  of  the  two  processes,  and  which  make  necessary  the 
differential  diagnosis  of  labyrinth  suppuration  from  cerebellar  abscess. 
In  considering  these  symptoms,  we  shall  at  the  same  time  consider  them 
from  the  standpoint  of  the  differential  diagnosis. 

III.      SPECIAL  SYMPTOMS. 

These  are  vertigo,  nystagmus  and  equilibrium  disturbance.  They 
form  a  symptom  complex  which  because  of  their  association  and  de- 
pendence upon  one  another,  both  in  labyrinth  suppuration  and  cere- 
bellar abscess,  must  be  considered  together.  These  symptoms  may  be 
considered  as  the  several  manifestations  of  the  one  phenomenon  which, 
when  most  pronounced,  manifests  itself  still  further  with  nausea  and 
vomiting. 

Alexander  has  noted  that  every  attack  of  vertigo,  independent  of 
cause,  is  accompanied  with  rhythmic  nystagmus,  and  I  would  add,  too, 
with  equilibrium  disturbances. 

On  the  other  hand,  rythmic  nystagmus  may  be  observed  without 
vertigo,  as  illustrated  by  the  low  degrees  of  galvanic  nystagmus  ob- 


LABYRINTH  PAPERS.  59 

tainable  without  the  subjective  sensation  of  vertigo  (a  fact  first  pointed 
out  by  the  writer). 

Likewise,  equilibrium  disturbance  may  be  obtained  in  diseases  of  the 
centripetal  tracts  to  the  cerebellum  without  vertigo,  providing  the  pro- 
cess is  not  a  very  acute  one.  Panse  (Schwindel,  1902),  Mackenzie 
(A.  f.  O.,  1908). 

The  opinion  of  Marburg  is  that  the  symptoms  of  vertigo,  nystagmus 
and  equilibrium  disturbance  in  case  of  cerebellar  abscess  arise  from 
irritation  of  Deiter's  nucleus  and  necessarily  are  of  the  same  char- 
acter (so  called  vestibular)  as  those  found  in  irritative  lesions  of  the 
labyrinth  or  vestibular  nerve.  On  the  other  hand,  Alexander  (M.  /. 
O.,  1906)  claims  that  the  character  of  the  nystagmus  in  cerebellar 
abscess  is  distinctly  horizontal  and  of  long  excursions  in  contradistinc- 
tion to  the  vestibular  nystagmus  which  is  rotatory  and  of  relatively 
short  excursions. 

Of  more  importance  than  the  character  is  the  direction  of  the  nystag- 
mus. Oppenheim,  Koerner,  Panse,  and  more  recently  Alexander,  Neu- 
mann, Barany  and  others  of  the  Politzer  school  have  shown  that  tho 
direction  of  the  nystagmus  in  cerebellar  abscess  may  be  to  either 
side,  in  the  vast  majority  of  cases  it  is  toward  the  diseased  side. 

In  spite  of  the  fact  that  labyrinth  suppuration  and  cerebellar  ab- 
scess present  a  marked  resemblance  so  far  as  the  vertigo,  nystagmus 
and  equilibrium  disturbances  are  concerned,  Neumann  contends,  and 
is  amply  supported  by  others,  that  these  very  symptoms,  and  more 
especially  the  nystagmus,  are  the  symptoms  which  aid  us  most  in  the 
differential  diagnosis. 

It  would  seem  that  the  difficulties  of  diagnosis  would  be  much  in- 
creased when  we  have  a  combination  of  the  two  conditions,  but  even 
here  a  differentiation  in  most  cases  is  not  so  difficult  as  appears  at  first 
thought.  In  a  case  of  combined  labyrinth  suppuration  with  cerebellar 
abscess  the  symptoms  and  signs  of  the  more  recent  cerebellar  abscess 
outweigh  those  of  the  longer  standing  labyrinth  suppuration.  If  the 
symptoms  and  signs  of  cerebellar  abscess  are  sufficiently  pronounced 
to  make  a  positive  diagnosis,  it  remains  only  to  determine  the  negative 
reactibility  of  the  labyrinth  to  complete  the  diagnosis.  In  such  a  case 
(cerebellar  abscess  following  labyrinth  suppuration)  there  is  always  an 
appreciable  lapse  of  time  between  the  manifestations  of  these  two  pro- 
cesses. The  patient,  if  conscious,  will  be  able  to  give  a  history  describ- 
ing his  attack  of  labyrinth  suppuration  (sudden  deafness,  vertigo  with 
nausea,  vomiting  and  equilibrium  disturbance  so  pronounced  that  he 


60     LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

was  compelled  to  seek  the  recumbent  position,  lasting  over  a  period  of 
several  days)  so  characteristic  that  a  mistake  in  diagnosis  of  labyrinth 
suppuration  seems  almost  impossible.  If  in  combination  with  the  above 
history  we  are  able  to  determine  that  deafness  is  absolute  and  the  static 
labyrinth  is  nonreactive  to  one  or  more  of  the  usual  tests  the  diagnosis 
is  certain.  On  the  other  hand,  if  we  find  the  patient  in  a  comatose 
condition,  some  member  of  the  family  or  friend  will  be  able  to  supply  a 
history  which,  together  with  negative  reactibility  of  the  static  labyrinth 
determined  at  the  time  of  our  examination,  are  quite  sufficient  for  us 
to  make  a  positive  diagnosis.  I  might  add  that  these  latter  are  the  cases 
which  are  prone  to  show  the  deviation  conjugee  (see  above)  to  the 
opposite  (well)  side. 

The  nystagmus  of  labyrinth  suppuration  and  that  of  cerebellar  ab- 
scess differ  not  only  in  character  and  direction,  as  already  pointed  out, 
but,  too,  in  intensity.  This  intensity  differs  with  the  stage  of  the  pro- 
cesses. In  labyrinth  suppuration  it  is  most  intense  at  the  onset  and 
then  diminishes  constantly  with  an  almost  mathematic  precision ;  on  the 
contrary,  in  cerebellar  abscess  the  intensity  tends  to  increase,  is  rather 
inconstant,  and  with  frequent  intermissions.  As  a  result  we  find  that 
the  nystagmus  of  cerebellar  abscess  is  rarely  so  intense  as  that  of  early 
labyrinth  suppuration  (first  few  days).  On  the  other  hand,  it  is  always 
more  intense  than  that  of  late  labyrinth  suppuration  (several  weeks  or 
months  after  the  acute  attack).  Since  cerebellar  abscess  does  not  de- 
velop until  long  after  the  nystagmus  of  early  labyrinth  suppuration  has 
had  time  to  subside,  it  must  follow  that  a  marked  nystagmus  at  this 
time  must  be  due  rather  to  cerebellar  abscess, — and  not  to  labyrinth 
suppuration. 

Let  us  consider  next  the  nystagmus  from  another  standpoint.  A 
case  with  the  history  and  findings  of  middle  ear  suppuration  presents 
itself  with  nystagmus  to  the  opposite  (well)  side.  There  are  three 
possibilities,  namely :  (i)  labyrinth  suppuration,  (2)  cerebellar  abscess, 
(3)  combined  cerebellar  abscess  with  late  labyrinth  suppuration. 

(1)  Labyrinth    suppuration    (see  first  paper)    would  be 
determined  by  the  absolute  deafness  and  the  negative  reactibility  of  the 
nonacoustic  labyrinth,  together  with  the  absence  of  symptoms  of  cere- 
bellar abscess. 

(2)  Cerebellar   abscess  (exceptionally  rare)  would  be  de- 
cided by  the  positive  hearing  and  the  positive  reactibility  of  the  static 
labyrinth,  together  with  positive  symptoms  of  cerebellar  abscess. 

(3)  Combined    cerebellar    abscess    with    labyrinth 


LABYRINTH  PAPERS.  61 

suppuration  (very  rare)  would  be  decided  by  the  negative  hear- 
ing and  the  negative  reactibility  of  the  static  labyrinth  with  positive 
symptoms  of  cerebellar  abscess. 

A  second  case,  with  the  history  and  findings  of  middle  ear  suppura- 
tion, may  present  itself  with  nystagmus  to  the  same  (diseased)  side. 
We  have  again  three  possibilities,  namely :  ( I )  irritative  lesion  of  the 
labyrinth,  (2)  cerebellar  abscess,  (3)  combined  cerebellar  abscess  with 
late  labyrinth  suppuration. 

(1)  Irritative    lesion    of    the     labyrinth  ( see  former 
paper)  would  be  decided  by  the  positive  hearing,  the  positive  caloric 
reactibility  and  the  increased  reactibility  of  the  labyrinth  to  turning 
and  the  galvanic  current,  with  perhaps  (dependent  upon  the  presence 
of  fistula)  compression  and  aspiration  nystagmus. 

(2)  Cerebellar    abscess    would  be  decided  by  the  positive 
hearing  and  the  more  or  less  positive  reactions  from  the  static  labyrinth, 
and  in  addition  the  presence  of  symptoms  of  cerebellar  abscess  referred 
to  in  the  preceding  pages. 

(3)Combined  cerebellar  abscess  with  labyrinth 
suppuration  would  be  decided  by  the  negative  hearing  and  the 
negative  reactibility  of  the  static  labyrinth,  findings  which  alone  are 
sufficiently  characteristic  for  a  positive  diagnosis  of  a  combination  of 
these  two  processes.  These  findings,  i.  e.,  nystagmus  to  the  diseased 
side  with  negative  reactions  from  the  static  labyrinth  may  be  accepted 
as  pathognomonic  signs  of  combined  cerebellar  abscess  and  labyrinth 
suppuration. 

The  Vertigo  of  labyrinth  suppuration  like  the 
nystagmus,  is  most  pronounced  at  the  onset  of  the  attack  and  diminishes 
constantly  with  the  same  mathematic  precision,  however  more  rapidly 
than  the  nystagmus,  and  practically  disappears  in  about  a  week,  after 
which  it  reappears  only  upon  making  rapid  movements  of  the  head 
and  then  lasts  but  a  few  seconds. 

The  Vertigo  of  cerebellar  abscess  is  rather  less  in- 
tense than  that  of  early  labyrinth  suppuration  (first  week)  but  more  in- 
tense than  that  of  late  labyrinth  suppuration.  In  cerebellar  abscess, 
instead  of  diminishing,  the  vertigo  tends  rather  to  increase  with  the 
progress  of  the  abscess.  Again,  the  vertigo  of  cerebellar  abscess  is 
more  variable  than  that  of  labyrinth  suppuration. 

Nausea  and  vomiting  invariably  accompany  the  vertigo  of  early 
labyrinth  suppuration,  the  nausea  being  the  more  pronounced  of  the 
two  symptoms.  In  this  instance  the  nausea  is  the  result  of  the  vertigo 


62      LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

On  the  other  hand,  in  cerebellar  abscess — altho  the  nausea  and  vomit- 
ing may  at  times  result  from  the  vertigo — it  more  often  does  not.  In 
the  latter  instance  (cerebellar  abscess)  nausea  is  less  pronounced  than 
the  vomiting.  The  vomiting  is  more  like  the  so  called  cerebral  vomit- 
ing, forcible  expulsive  vomiting  without  nausea.  Koerner  attributes 
this  cerebral  vomiting  to  any  condition  which  may  produce  increase  of 
the  intracranial  pressure. 

Equilibrium  disturbance,  like  the  nystagmus  and  vertigo 
of  labyrinth  suppuration,  is  most  pronounced  in  the  early  stage,  and  is 
of  the  type  already  described  (see  former  papers).  The  patient  tends 
to  fall  laterally  in  the  plane  (frontal)  of  his  nystagmus  toward  the 
diseased  side.  This  falling  in  early  labyrinth  suppuration  is  an  ac- 
companying phenomena  of  the  nystagmus ;  in  other  words,  "reaction 
falling."  (Barany,  Phys.  u.  Path,  des  Bogeng.  Appar.,  1908.)  On  the 
contrary,  the  equilibrium  disturbances  of  cerebellar  abscess  appear  in 
the  later  stages.  Altho  the  nystagmus  in  the  two  processes  is  to  oppo- 
site sides,  the  tendency  to  fall  in  both  cases  is  to  the  same  side.  In 
cerebellar  abscess,  since  the  nystagmus  is  to  the  diseased  side,  we  can- 
not explain  the  falling  to  the  diseased  side  as  reaction  falling  the  result 
of  the  nystagmus.  It  is  probably  due  more  to  the  hemiparesis  and 
hemiataxia  of  the  diseased  side,  as  suggested  by  Alexander.  This  ex- 
planation receives  further  support  in  view  of  the  fact  that  the  so  called 
"asynergie  cerebelleuse"  is  really  a  form  of  ataxia  of  cerebellar  origin. 

In  closing  the  subject  of  differential  diagnosis  of  labyrinth  suppura- 
tion from  cerebellar  abscess  we  shall,  for  the  sake  of  convenience,  sum- 
marize the  more  important  differential  symptoms  in  the  form  of  a  table 
(see  below).  Furthermore,  since  a  differentiation  of  these  two  pro- 
cesses would  not  be  complete  without  consideration  of  a  third  pro- 
cess, namely,  combined  labyrinth  suppuration  and  cerebellar  abscess, 
we  shall  include  it  in  our  table;  besides,  the  frequency  and  importance 
of  this  third  condition  demand  it.  The  table  follows : 

COMBINED        LABYRINTH 
CEREBELLAR   ABSCESS.  SUPPURATION  AND 

CEREBELLAR   ABSCESS. 

I. — Absolute   deafness  of      i. — Positive  hearing  or      i. — Absolute  deafness. 
sudden  onset.  rests  of  hearing. 

2. — Vertigo     intense    at      2. — Vertigo  less  intense,       2. — History     of     having 
first,   but   constantly  but  increasing   with  had    vertigo    of   the 

diminishing,      with  the    progress  of  the  type    of   early    laby- 

the  sensation  of  ob-  abscess.  rinth    suppuration 

jects     rolling    about  which      has     dimin- 

the  axis  of  vision.  ished,     again     reap- 

pearing with  increas- 
ing intensity. 


LABYRINTH  PAPERS. 


3-— 


S. — Removal  of  the  laby- 
rinth is  followed  by 
improvement  of  the 
headache  or  other 
symptoms  which  may 
suggest  meningitis. 


4-— 


LABYRINTH  SUPPURA- 
TION. 

3. — Pronounced  spon- 
taneous rotatory  nys- 
tagmus to  the  well 
side  in  the  early 
stages,  but  progress- 
ively diminishing  in 
intensity. 


4. — Equilibrium  disturb- 
ances marked  in  the 
early  stages  with 
tendency  to  fall  to 
the  diseased  side  (re- 
action falling).  Less 
marked  but  apparent 
in  the  late  stage. 


5. — Reactibility    of     the       5. — 
static  labyrinth  nega- 
tive. 

6. — Headache,       when       6. 
present,     is     diffuse 
over  the  lateral  half 
of  the  affected  side. 

7. — No  symptoms  of  cere-       7. 
bellar  abscess. 


CEREBELLAR    ABSCESS. 


Spontaneous  h  o  r  i  - 
zontal  nystagmus  of 
longer  excursions 
than  that  of  laby- 
r  i  n  t  h  suppuration 
(Alexander)  to  the 
diseased  side  or  rota- 
tory to  either  side, 
however  in  the  vast 
majority  of  cases  to 
the  diseased  side,  in- 
creasing in  intensity. 
Equilibrium  disturb- 
ances less  marked 
than  in  early  and 
more  marked  than 
in  late  labyrinth  sup- 
puration. Patient 
tends  to  fall  to  the 
diseased  side  because 
of  muscular  weak- 
ness and  ataxia  in 
the  extremities  of 
the  diseased  side 
(Alexander). 
Reactibility  of  the 
static  labyrinth  posi- 
tive. 

Circumsctibed  occip- 
ital headache  upon 
the  affected  side,  or 
less  frequent  frontal 
headache. 

Positive  symptoms  of 
cerebellar  abscess; 
localized  occipital 
tenderness,  rigidity 
of  the  neck,  liomo- 
lateral  hemi-paresis 
and  hemi-anesthesia, 
cerebellar  ataxia, 
optic  neuritis  or 
choked  disc,  impair- 
ment of  intellect 
(slow  cerebration), 
great  loss  of  body 
weight,  bradycardia. 
Removal  of  the  laby- 
rinth is  not  indicated; 
hence  in  this  case  no 
comparison  can  be 
made. 


COMBINED     LABYRINTH 

SUPPURATION    AND 
CEREBELLAR    ABSCESS 

3. — Spontaneous  rotatory 
nystagmus  of  laby- 
rinth suppuration 
has  almost  disap- 
peared and  the  nys- 
tagmus of  cerebellar 
abscess  type  has  ap- 
peared (see  column 
to  the  left). 


4. — Equilibrium  disturb- 
ances of  the  same 
type  as  that  found  in 
cerebellar  abscess 
(see  opposite  column 
to  the  left). 


5.— Reactibility  of  the 
static  labyrinth  nega- 
tive. 

6. — Same  as  that  found  in 
the  opposite  column 
to  the  left. 


7. — Positive  symptoms  of 
cerebellar  abscess 
outweigh  those  of 
the  late  labyrinth 
suppuration. 


8. — Removal  of  the  laby- 
rinth is  not  followed 
by  improvement  as 
in  the  case  of  simple 
labyrinth  suppura- 
tion. On  the  con- 
trary, the  symptoms 
of  the  cerebellar  ab- 
scess are  often  in- 
creased by  the 
trauma  of  the  oper- 
ation. 


d|      LABYRINTH  SUPPURATION  FROM  CEREBELLAR  ABSCESS. 

I  have  not  discussed  the  value  of  the  lumbar  puncture  in  the  differ- 
ential diagnosis  of  these  two  conditions  for  evident  reasons :  First,  be- 
cause the  contrast  is  not  sufficiently  great  to  be  of  any  aid  to  us  in  the 
differentiation ;  both  processes  showing  relatively  the  same  conditions, 
namely,  escape  of  cerebrospinal  fluid  with  increased  pressure,  fluid 
slightly  clouded  containing  few  leucocytes  and  many  lymphocytes,  but 
no  bacteria  (except  in  case  where  the  abscess  has  ruptured)  and  the 
fluid  shows  slight  tendency  to  coagulation  into  delicate  threads  after 
long  standing.  Secondly,  because  the  danger  of  rupture  of  the  abscess 
from  the  sudden  release  of  intracranial  pressure  is  too  great  to  warrant 
the  procedure  in  case  of  cerebellar  diseases. 

The  lumbar  puncture  is  better  adapted  to,  and  is  of  more  value  in. 
the  differentiation  of  other  processes. 


THE  DIFFERENTIATION  OF  LABYRINTH  SUPPURATION 
FROM  AFFECTIONS  OF  THE  EIGHTH  NERYK. 


F^ROM  the  etiologic  standpoint  the  most  important  diseased  con- 
ditions demanding  a  differentiation  from  labyrinth  suppura- 
tion are  the  diseases  of  the  labyrinth  secondary  to  middle  ear 
suppuration  ;  from  the  anatomic  standpoint,  or  in  other  words  from  the 
standpoint  of  localization,  are  the  diseases  of  the  cerebellum  (especially 
cerebellar  abscess)  and  the  diseases  of  the  eighth  nerve.  The  former 
(diseases  of  the  labyrinth)  were  discussed  and  differentiated  in  the 
first  paper  upon  Differential  Diagnosis  ;  cerebellar  abscess  in  the  fol- 
lowing paper,  and  it  remains  for  us  to  do  the  same  with  the  diseases  of 
the  nerve  in  the  present  paper. 

As  is  well  known,  a  differential  diagnosis  of  two  or  more  diseased 
conditions  implies  first  similarity,  secondly  dissimilarity.  The  similar- 
ity makes  the  differention  necessary,  and  the  dissimilarity  makes  it  pos- 
sible. 

The  similarity  of  symptoms  and  signs  of  destructive  lesions  of  the 
labyrinth  (deafness,  vertigo,  equilibrium  disturbances,  spontaneous 
nystagmus  to  the  sound  side  and  negative  reactibility  of  the  static  laby- 
rinth) to  those  of  destructive  lesions  of  the  nerve  are  quite  apparent; 
on  the  other  hand  the  dissimilarity  of  the  history  and  otoscopic  findings 
are  just  as  apparent.  In  spite  of  these  apparent  dissimilarities,  we  find 
cases  where  there  is  a  possibility  of  confusion  ;  a  striking  illustration 
of  which  was  observed  by  the  writer  in  a  case  of  multiple  neuritis  in- 
volving the  eighth  nerve. 

In  this  case  a  herpes  zoster  bleb  on  the  tympanic  membrane  obscured 
the  anatomic  relationship  and  at  the  same  time  produced  swelling  of 
the  membrane  resembling  that  of  acute  otitis  media  or  an  acute  ex- 
acerbation of  the  chronic  middle  ear  suppuration.  A  similar  case  is 
reported  by  Hartmann  (Politzer's  Lehrbuch  Ohrenheilkund.,  1908, 
pcige  202.)  The  case  seen  by  the  writer  has  been  reported  by  Ruttin 
(Sitzung  der  Oesterreich.  Otol.  Gesellschaft,  Wein,  Januar,  1908.) 

A  further  possibility  of  confusion  may  be  afforded  by  errors  in  the 
history,  which  is  too  often  unreliable,  a  fact  patent  to  everyone  who  has 
been  obliged  to  take  a  great  number  of  histories,  especially  in  dis- 
pensary practice. 

5 


66  DIFFERENTIATION  FROM  AFFECTIONS  OF  EIGHTH  XERl'E. 

In  this  paper  it  will  not  be  necessary  to  consider  all  of  the  diseased 
conditions  of  the  nerve,  since  with  most  of  them,  including  tumor,  the 
similarity  is  not  sufficient  nor  is  the  onset  acute  enough  to  permit  con- 
fusion with  labyrinth  suppuration.  We  shall  limit  our  discussion 
rather  to  neuritis  of  the  Eighth  Nerve:  besides,  a  recognition  of 
neuritis  serves  as  a  foundation  for  the  recognition  of  the  other  dis- 
eased conditions  of  the  nerve. 

As  in  the  case  of  the  seventh,  so  in  the  case  of  the  eighth  nerve, 
neuritis  may  occur  isolated  or  in  combination  with  polyneuritis  in- 
volving other  cranial  nerves.  Oppenheim  (Lehrbuch  der  Nerv.  Krank., 
1908)  refers  to  a  form  of  polyneuritis  limited  to  the  cranial  nerves. 

Combined  seventh  nerve  paresis  with  herpes  zoster  (fifth  nerve)  has 
been  observed  and  reported  by  Politzer  (Lehrbuch  der  Ohrenheilk., 
1908,  page  611)  ;  Huet  Fraser  (Lancet  I,  page  18,  1904)  ;  G.  G.  Mor- 
rice  (St.  Earth.  Hospital  Reports,  vol.  xxxii,  page  167,  1903)  ;  with 
sensibility  disturbances  of  fifth  nerve  origin,  by  Huet  (Soc.  Neurol., 
1904,  Jan.  /th)  ;  by  Donath,  Spiller,  Maurice,  Mazurkiewitz  and  others. 

Combined  seventh  nerve  paresis  with  optic  neuritis  has  been  observed 
and  reported  by  Wilfred  Harris  (Brit.  Med.  Jour.,  Jan.,  1903)  ;  by 
Shumway  (Jour.  A.  M.  Assoc.,  vol.  cliv,  No.  6,  page  63,  1905). 

Combined  eighth  (acoustic)  nerve  paresis  with  fifth  nerve  paresis 
reported  by  Kaufman  (Z.  f.  Ohrenheilk.,  1897)  ;  Hammerschlag  (A.  f. 
Ohrenheilk.,  bd.  xlv)  ;  Sarae  (Z.  f.  Ohrenheilk.,  1904)  ;  Lannois  (Con- 
gress de  Bordeaux,  1904)  ;  Gradenigo  (Ann.  cle  Mai  de  1'uereille, 
1908). 

Combined  eighth  nerve  paresis  with  seventh  nerve  paresis  has  been 
reported  by  Rosenbach  (Zentralblatt  f.  Nerv.,  1887)  ;  Frankl  Hochwart 
(der  Menierische  Symptom  Complex,  Wien,  1897)  and  others. 

Combined  eighth  nerve  paresis  with  fifth  and  seventh  nerve  paresis 
has  been  reported  by  Koerner  (Munch.  Med.  Wochensch.  nr.  i,  seite 
6,  1904). 

Isolated  paresis  of  the  eighth  nerve  has  been  reported  by  Bing  (Wien. 
Med.  Wochenschr.,  1880). 

Isolated  paresis  of  the  cochlear  branch  of  the  eighth  nerve  has  been 
reported  by  Gradenigo  and  Barnick  (Arch.  f.  Ohrenheilk.,  bd.  28)  ; 
Wittmaach  (Zeitsch.  f.  Ohrenheilk.,  bd.  53)  ;  Hammerschlag,  Kauf- 
mann  and  others. 

Isolated  paresis  of  the  vestibular  branch  of  the  eighth  nerve  has  been 
reported  by  Ruttin  (Sitz.  der  Oesterr.  Otol.  Gesell.,  Wien,  Jan.,  1908). 


LABYRINTH  PAPERS.  67 

In  looking  over  the  literature  I  find  that  the  cases  of  isolated  neuritis 
of  the  eighth  nerve  are  fewer  than  those  of  polyneuritis  involving  tht. 
eighth  nerve.  In  the  case  of  polyneuritis  of  the  cranial  nerves,  tht 
eighth  nerve  appears  to  be  somewhat  less  vulnerable  than  the  remain- 
ing nerves ;  however,  with  our  increased  knowledge  of  the  functions 
and  reactions  of  the  vestibule  and  the  vestibular  nerve,  our  ability  to 
recognize  pathologic  changes  in  the  eighth  nerve  will  be  increased,  and 
Avith  it  will  come  an  increased  number  of  these  cases  to  be  reported. 

The  causes  of  eighth  nerve  neuritis  are  generally  the  same  as  those 
of  polyneuritis  of  the  cranial  nerves.  Bezold  divides  the  causes  into 
three :  (a)  infectious ;  (b)  constitutional ;  (c)  toxic. 

(a)  Infectious.    Polyneuritis  during  or  after  the  infectious  dis- 
eases is  not  uncommon.    Of  the  infectious  diseases  causing  neuritis  we 
find  prominently  tuberculosis,  especially  the  acute  miliary  form  with 
fever ;  typhoid  fever,  especially  those  cases  running  very  high  tempera- 
ture:  scarlet  fe-rcr,  influenza,  and  diphtheria.    The  above  fevers  cause 
the  acute  forms  of  neuritis. 

Besides  these  acute  forms,  we  may  have  the  more  chronic  primary 
gray  atrophy  of  the  nerve  similar  to  that  of  the  optic  nerve  in  metalncs; 
illustrated  by  the  progressive  deafness  of  tabetic  patients  (from  2  to 
10  per  cent. — Oppenheim).  Relative  to  syphilis  as  a  cause  of  neuritis, 
the  writer  observed  two  cases  where  the  patients  manifested  hereditary 
syphilis  with  previous  interstitial  keratitis,  and  one  in  addition  pre- 
sented optic  nerve  atrophy. 

(b)  Constitutional  causes  are  leukemia,  arteriosclerosis,  car- 
cinoma, diabetes,  gout,  malaria  and  cretinism.     Neuritis    from    all    of 
these  causes  has  been  well  authenticated  and  reported.     These  causes 
are  prone  to  produce  the  isolated  and  unilateral  forms  of  neuritis. 

(c)  Toxic.     These  are  more  frequently  due  to  quinine  and  the 
salicylatcs;  less  frequently  to  tobacco  and  alcohol,  and  still  less  fre- 
quently to  lead,  arsenic  and  the  inhalation  of  carbon  dioxide.     These 
tend  to  produce  a  form  of  retrolabyrinthine    neuritis    similar    to    the 
retrobulbar  neuritis  and  resembles  it  furthermore  in  its  amenability  to 
treatment.     Oppenheim  suggests  that  in  the  toxic  forms,  especially  in 
those  cases  from  alcohol,  tobacco,  lead  and  arsenic,  there  may  be  two 
factors  producing  the  neuritis :  the  poison  acting  as  a  predisposing  and 
the  exposure  to  cold  and  dampness  as  exciting  causes. 

(d)  Refrigeratory,  or  so-called  rheumatic,  was  not  in- 
cluded in  the  above  classification  of  causes  since  it  is  not  exactlv  known 


68   DIFFERENTIATION  FROM  AFFECTIONS  OF  EIGHTH  NERrE. 

what  this  cause  is.  In  most  of  these  cases  there  appears  to  be  two 
factors :  first,  auto-intoxication,  and  secondly,  exposure  to  draught  of 
air ;  at  least,  this  last  mentioned  is  the  most  frequently  assigned  cause 
by  the  patient.  On  the  other  hand,  Alexander  (Arch.  f.  Psychiatric, 
bd.  35,  heft  3)  after  a  careful  study  of  the  microscopic  pathology, 
suggests  that  the  so-called  rheumatic  neuritis  is  probably  of  infectious 
(bacterial)  origin.  The  illustrated  plates  which  he  produces  would 
suggest  such  an  origin ;  however,  he  was  unable  to  prove  the  presence 
of  micro-organisms  with  the  Gram  and  methyline-blue  stains  which  he 
used.  There  are,  besides,  two  clinical  facts  which  further  support  the 
theory  of  infectious  origin  for  the  so-called  rheumatic  polyneuritis ; 
first,  the  usual  presence  of  slight  fever ;  secondly,  the  finding,  although 
rare,  of  two  members  of  the  same  family  simultaneously  affected  with 
Bell's  palsy. 

PATHOLOGY. 

Evidently  the  pathology  is  not  the  same  in  all  forms  of  eighth  nerve 
neuritis.  The  pathology  in  some  of  these  forms  is  still  unknown ;  how- 
ever, in  the  acute  cases  thus  far  studied  it  was  found  that  the  nerve 
stem  was  infiltrated  and  swollen,  while  the  nerve  fibers  were  conse- 
quently destroyed  and  later  replaced  by  proliferated  connective  tissue 
elements  resulting  eventually  in  a  sclerosis  of  the  nerve  (Bezold,  Lehr- 
buch  der  Ohrenheilk.,  1906). 

Hammerschlag  claims  that  the  pathology  of  eighth  nerve  neuritis  is 
similar  to  that  of  seventh  nerve  neuritis  with  the  exception  that  in  the 
eighth  nerve  neuritis  the  end  organ  in  the  labyrinth  is  simultaneously 
affected,  while  Bezold,  on  the  other  hand,  believes  that  the  end  organ 
is  secondarily  affected.  In  the  case  of  neuritis  from  constitutional 
causes,  at  least  in  one  variety — leukemia — Bezold  found  actual  leu- 
kemic  infiltration  of  the  nerve  stem. 

The  neuritis  of  toxic  origin  suggests  a  pathology  similar  to  that  of 
the  retrobulbar  neuritis ;  furthermore  it  behaves  clinically  the  same,  it 
is  generally  bilateral,  and  the  prognosis  is  as  favorable  in  the  one  as 
in  the  other  under  proper  treatment;  besides  the  two  nerves,  II  and 
VIII,  may  be  simultaneously  affected  by  the  same  toxin. 

In  the  so-called  rheumatic  form  the  pathology  would  suggest  an 
infectious  origin,  but  up  to  the  present  time  the  presence  of  the  micro- 
organisms have  not  been  demonstrated. 

The  post-syphilitic  and  the  hereditary  syphilitic  neuritis  of  the  eighth 
nerve  from  the  clinical  standpoint  would  suggest  two  separate  path- 


LABYRINTH  PAPERS.  69 

ologic  processes ;  the  former,  an  acute  neuritis,  and  the  latter  rather  that 
of  a  primary  gray  atrophy.  This  suggestion  receives  further  support 
by  the  similar  findings  and  prognoses  of  these  two  forms  of  changes 
found  in  the  optic  nerve  from  the  same  causes. 

PROGNOSIS. 

The  prognosis  depends  in  a  measure  upon  the  cause.  In  the  post- 
infectious  neuritis  the  prognosis  is  generally  favorable,  as  in  the  case 
of  neuritis  of  the  other  cranial  nerves  from  the  same  cause.  The  prog- 
nosis in  the  constitutional  is  generally  less  favorable,  and  is  in  propor- 
tion to  the  prognosis  of  the  primary  condition  behind  it.  The  prognosis 
of  the  toxic  forms  is  the  most  favorable  under  suitable  treatment  and 
by  stopping  the  continuance  of  the  poison  which  brought  about  the  con- 
dition. 

SYMPTOMATOLOGY. 

In  the  cases  of  atrophy  following  neuritis  the  symptoms  and  signs, 
with  the  exception  of  the  otoscopic  findings,  are  the  same  as  those  of 
late  labyrinth  suppuration.  Since  however  in  atrophy  the  symptoms 
and  signs  are  those  of  atrophy  and  not  those  of  neuritis,  we  shall  not 
consider  them  further  in  this  paper.  The  object  of  this  paper  is  rather 
to  discuss  the  symptoms  and  signs  of  acute  neuritis  of  the  eighth  nerve 
and  its  differentiation  from  acute  labyrinth  suppuration. 

The  symptomatology  of  acute  neuritis  depends  upon  the  cause  and 
extent  of  the  process.  Although  neuritis  of  the  eighth  nerve  occurs 
about  as  often  unilateral  as  bilateral,  we  shall,  in  order  to  bring  out 
more  clearly  the  symptoms,  refer  especially  to  the  unilateral  form.  In 
the  cases  of  bilateral  neuritis  it  also  frequently  happens  that  one  side 
is  much  less  affected  than  the  other,  and  in  this  way,  as  in  the  case  of 
double  optic  neuritis,  the  pathologic  changes  of  the  less  affected  nerve 
frequently  escape  detection  and  the  nerve  is  incorrectly  pronounced 
normal.  In  all  cases  of  unilateral  eighth  nerve  neuritis  more  careful 
attention  to  the  other  nerve  will  frequently  enable  us  to  avoid  such 
mistakes  and  oversights. 

Let  us  consider,  first,  the  typical  symptoms  and  signs  of  complete 
unilateral  neuritis  of  the  eighth  nerve,  and  later  we  shall  see 
that  the  more  the  symptoms  and  signs  deviate  from  the  typical 
the  easier  the  differential  diagnosis  is. 

The  following  symptoms  and  signs  of  acute  eighth  nerve  neuritis 
are  more  or  less  abrupt  in  onset,  with  as  a  rule  some  fever  and  malaise 


70  DIFFERENTIATION  FROM  AFFECTIONS  OF  EIGHTH  NERVE. 

which  may  be  more  or  less  obscured  by  the  more  intense  focal  symp- 
toms. 

These  are : — 

i — T  innitus  or  Subjective  Noises.  These  in  most 
cases  are  quite  pronounced.  The  more  acute  the  onset  and  the  more 
complete  the  involvement,  the  less  pronounced  and  the  shorter  the  dura- 
tion of  this  symptom.  Theoretically,  every  attack  of  eighth  nerve  neuri- 
tis should  present  this  symptom  ;  however,  it  may  be  somewhat  obscured 
by  the  more  intense  vertigo  and  thereby  escape  observation  in  a  small 
minority  of  cases.  In  some  cases  the  tinnitus  continues  in  spite  of 
complete  deafness ;  two  of  such  cases  having  been  reported  with  gal- 
vanic reaction  of  the  acoustic  nerve  by  Dr.  A.  V.  Mackenzie  (\Yein. 
Klin.  Wochenschr.,  1908,  no.  n).  In  these  cases  tinnitus  continues 
until  complete  destruction  (degeneration)  of  the  nerve  takes  place. 

2 — D  e  a  f  n  e  s  s,  complete,  if  the  neuritis  is  complete.  This  follows 
quickly  upon  tinnitus  in  the  acute  cases.  There  is  a  loss  ot  perception 
for  all  tones  and  noises  upon  the  affected  side,  demonstrated  by  the 
small  B!  fork  (Bezold)  and  the  three  meter  speaking  tube,  alluded  to 
in  previous  papers.  Bone  conduction  is  very  much  shortened,  Rinne 
is  negative  with  no  air  conduction,  Weber  to  the  opposite  side,  the 
acumeter  and  Galton's  whistle  are  not  heard  upon  the  affected  side ; 
however,  the  absolute  unreliability  of  these  last  two  mentioned  tests 
for  one-sided  deafness  is  well  known. 

3 — V  e  r  t  i  g  o.  The  vertigo  is  most  intense  and  is  associated  with 
nausea  and  vomiting.  The  patient  suffers  typical  (Drehschwindel) 
turning  vertigo,  i.  e.,  he  surfers  the  sensation  as  though  the  room  were 
tumbling  about  him  in  the  frontal  plane  or  else  the  sensation  as  though 
he  himself  were  falling  in  the  frontal  plane  (laterally).  This  vertigo 
lasts  several  days  or  perhaps  a  week,  depending  upon  the  extent  and 
intensity  of  the  process.  After  the  acute  condition  passes  over  the 
vertigo  diminishes  perceptibly  and  after  a  few  weeks  disappears  entire- 
ly in  those  cases  where  the  neuritis  subsides  and  resolution  takes  place. 
Slight  attacks  of  vertigo  of  brief  duration  may  however  continue  in 
those  unfavorable  cases  which  are  followed  by  atrophy. 

4 — E  q  u  i  1  i  b  r  i  u  m  disturbance.  This  is  found  constantly  in 
all  cases  of  neuritis,  and  is  in  direct  proportion  to  the  intensity  and  ex- 
tent of  the  neuritis.  At  the  beginning  of  the  neuritis,  the  patient  when 
attempting  to  stand  falls  toward  the  diseased  side  (typical  reaction  fall- 


LABYRINTH  PAPERS.  71 

ing.  This  falling  is  not  dependent  upon  the  false  impressions  which 
are  obtained  through  the  vision,  for,  on  the  contrary,  the  tendency 
to  fall  is  increased  when  the  eyes  are  closed.  The  disturbances  of 
equilibrium  are  so  marked  during  the  first  few  days  that  the  patient 
is  compelled  to  lie  down  for  safety.  This  character  of  equilibrium  dis- 
turbance is  dependent  upon  and  diminishes  with  the  vertigo  and 
eventually  disappears  entirely,  being  replaced  by  a  late  form  of  equilib- 
rium disturbance  in  those  cases  of  neuritis  followed  by  atrophy.  This 
late  form  of  equilibrium  disturbance  is  also  found  in  late  labyrinth  sup- 
puration. On  the  other  hand,  complete  recovery  from  all  equilibrium 
disturbances  occurs  where  complete  recovery  from  the  nueritis  takes 
place.  It  is  not  necessary  to  go  further  into  the  details  of  the  char- 
acter of  the  equilibrium  disturbances  since  they  are  otherwise  the  samr 
as  those  found  in  labyrinth  suppuration. 

5 — S  pontaneous  rotatory  nystagmus  to  the 
sound  side.  This  nystagmus  is  very  pronounced  and  is  due  to  the 
overbalance  of  the  normal  tonus  of  the  opposite  (sound)  nerve  already 
mentioned  in  the  first  two  papers  upon  labyrinth  suppuration. 

The  nystagmus  is  furthermore  rhythmic,  the  axial  excursions  of  the 
eye  balls  are  from  three  to  four  mm.  in  length  at  the  corneal  limbus. 
The  nystagmus  continues  for  a  longer  period  than  the  vertigo,  probably 
because  the  centers  have  become  more  or  less  adapted  to  the  changed 
condition.  In  those  cases  of  neuritis  which  terminate  with  resolution, 
the  nystagmus  disappears  entirely  or  may  even  reverse  its  direction  (to 
the  diseased  side)  ;  whereas  in  those  cases  of  neuritis  followed  by 
atrophy,  the  nystagmus  continues  for  months  and  eventually  disap- 
pears, according  to  most  authors.  From  a  careful  study  of  many  cases 
however  I  doubt  that  the  nystagmus  to  the  well  side  ever  entirely 
disappears,  for  in  my  experience  I  have  never  found  it  so,  even  in  cases 
where  the  destruction  has  been  of  several  years'  standing. 

6 — X  egative  caloric  reactibility  of  the  nonacous- 
tic  labyrinth  as  found  in  labyrinth  suppuration.  Xo  amount  of 
cold  or  hot  water  syringed  into  the  external  canal  produces  any  effect 
upon  the  existing  spontaneous  nystagmus.  This  negative  reactibility 
remains  pemanently  so  in  those  cases  followed  by  atrophy,  but  not  so 
in  those  cases  of  neuritis  which  result  in  recovery.  In  this  latter  in- 
stance the  reactibility  again  becomes  positive  as  before  the  attack. 

7 — S  hortened    duration    of    the     after-nystagmus. 


72  DIFFERENTIATION  FROM  AFFECTIONS  OF  EIGHTH  NERVE. 

This  sign  belongs  to  any  destructive  lesion  of  the  labyrinth,  the  nerve 
or  Deiter's  nucleus.  In  all  of  these  conditions  the  duration  of  the  after- 
nystagmus  to  the  affected  side  is  approximately  one-half  the  duration 
to  the  sound  side,  so  that  an  after-nystagmus  of  less  than  twelve  sec- 
onds to  the  diseased  side  combined  with  an  after-nystagmus  of  more 
than  twenty-four  seconds'  duration  to  the  sound  side  would  indicate 
a  loss  of  function  upon  the  diseased  side,  and  the  after-nystagmus  of 
twelve  seconds'  duration  to  the  diseased  side  is  purely  a  manifestation 
of  a  reaction  from  the  well  side.  For  a  further  explanation  of  these 
facts,  the  reader  is  referred  to  the  second  paper  upon  labyrinth  sup- 
puration. In  cases  of  atrophy  following  neuritis,  the  shortened  dura- 
tion of  the  after-nystagmus  to  the  diseased  side  remains  permanently 
so,  while  in  the  cases  resulting  in  recovery  the  duration  of  the  after- 
nystagmus  to  the  diseased  side  becomes  as  long  as  or  even  longer  than 
that  to  the  sound  side. 

8 — N  egative  galvanic  reactibilityof  the  a  ff  e  c  t  e  d 
nerve.  This  sign  is  more  or  less  present  in  both  labyrinth  suppuration 
and  neuritis ;  however  there  is  a  difference  between  the  reactions  in 
these  two  processes,  and  I  believe  this  difference  affords  us  one  of  the 
best  objective  means  for  the  differential  diagnosis.  For  this  reason, 
and  furthermore  since  it  was  promised  in  the  former  papers,  I  purpose 
here  to  outline  somewhat  more  in  detail  the  facts  concerning  the  gal- 
vanic reactions  of  the  labyrinth  and  the  nerve.  These  facts  have  been 
obtained  by  a  series  of  examinations  upon  normal  people,  those  with 
one-sided  labyrinth  affections  (both  irritative  and  destructive)  and  deaf 
mutes.  For  further  details  see  Arch.  f.  Ohrenheilk.,  1908. 

Briefly,  the  method  of  examination  was  with  an  apparatus  or  wall 
plate  fitted  with  three  essentials :  i — an  accurate  galvanometer  ;  2 — a 
switch  to  control  the  current,  and  3 — a  reversing  switch  by  which  one 
can  reverse  the  polarity  without  changing  the  electrodes.  The  two 
electrodes  are :  one  large  flat  one  to  be  appplied  preferably  to  the  op- 
posite hand,  and  the  other,  a  small  ball  electrode  to  be  applied  to  the 
region  of  the  ear;  the  latter  is  adjusted  to  a  handle  with  an  interrupter 
for  making  and  breaking  the  current.  In  making  the  examination  an 
assistant  is  required  to  control  the  current  switch  and  to  observe  the 
milliamperemeter,  while  the  examiner  observes  the  eye  movements 
holding  the  upper  lid  up  with  the  thumb. 

Both  electrodes  are  covered  with  gauze,  cotton  or  sponge,  and  are 


LABYRINTH  PAPERS.  73 

kept  well  moistened  with  warm  salt  solution.  The  more  saturated  the 
electrodes  are  kept,  the  less  the  resistance  and  better  the  patient  toler- 
ates the  examination.  To  aid  in  keeping  the  electrodes  well  moistened, 
I  also  have  the  skin  of  the  hand  and  the  region  of  the  ear  well  moist- 
ened with  the  same  salt  solution. 

As  previously  stated,  my  examinations  included  all  varieties  of  cases 
and  normal  people.  With  normal  people,  I  found  the  reaction  from  the 
static  labyrinth  to  be  more  prompt  than  from  the  acoustic  labyrinth ; 
normally,  from  three  to  six  milliamperes  were  required  to  produce  posi- 
tive reactions,  objectively  manifested  by  rotatory  nystagmus,  while 
from  two  to  four  milliamperes  more  were  required  to  produce  subject- 
ive vertigo.  The  difference  in  the  strength  of  currents  necessary  to 
produce  the  objective  and  the  subjective  reactions  explains  the  dis- 
crepancy in  the  figures  obtained  by  myself  and  those  of  the  earlier  in- 
vestigators who  recorded  only  the  subjective  vertigo  and  did  not  look 
for  the  objective  nystagmus.  In  all  my  figures  I  have  noted  the  ob- 
jective reaction  (rotatory  nystagmus)  and  have  ignored  the  more  crude 
and  less  reliable  subjective  reaction. 

The  examinations  were  all  made  with  the  patient  looking  straight 
ahead  at  a  distant  object,  thereby  preventing  all  inhibition  of  the  vestib- 
ular  reflex  which  might  otherwise  occur ;  besides,  observations  thus 
made  are  more  accurate  since  in  this  position  we  avoid  tremors  of  the 
eye  muscles  which  might  occur  if  the  patient  was  to  look  in  any  other 
direction. 

The  results  of  my  examinations  show : 

First — That  the  nystagmus  is  to  the  side  of  the  kathode;  second — 
away  from  the  anode ;  third — that  the  kathodal  reaction  balances  that 
of  the  anodal  reaction ;  and  fourth — with  the  same  electrodes  used,  the 
two  sides  balance  with  each  other. 

Any  imbalance  indicates  a  pathologic  condition  of  one  or  the  other 
labyrinth  or  nerve. 

i — When  the  kathodal  reaction  of  one  side  is  more  prompt  than  the 
kathodal  reaction  of  the  opposite  side,  it  indicates  either  a  pathologic 
irritation  of  that  side,  or  a  pathologic  destruction  of  the  opposite  side 
(labyrinth  or  nerve). 

2 — When  the  anodal  reaction  of  one  side  is  more  prompt  that  the 
anodal  reaction  of  the  opposite  side,  it  indicates  a  destructive  lesion  of 
that  side  or  an  irritative  lesion  of  the  opposite  side  (labyrinth). 

3 — When  the  kathodal  reaction  of  one  side  is  more  prompt  than  the 


74   niFFEREXTI.-lTIOX  FROM  AFFECTIOXS  OF  EIGHTH  XERVE. 

anodal  reaction  of  the  same  side,  it  indicates  either  an  irritative  lesion 
of  that  side  or  a  destructive  lesion  of  the  opposite  side  (labyrinth  or 
nerve) . 

The  above  findings  alone  are  not  sufficient  for  us  to  differentiate  be- 
tween these  two  processes  (irritative  lesion  of  one  side  or  destructive 
lesion  of  the  opposite  side).  The  differentiation  is  accomplished  by 
a  comparison  of  the  figures  with  those  of  the  normal.  Remembering 
that  the  normal  reaction  (nystagmus)  is  obtained  with  from  three  to 
six  milliamperes  with  either  electrode  it  follows  that  a  reaction  which 
requires  more  than  six  milliamperes  indicates  a  destructive  lesion,  and 
a  reaction  requiring  less  than  three  milliamperes  indicates  an  irritative 
lesion.  Furthermore,  if  normally,  four  ma,  with  the  kathode  to  the 
right  ear  will  produce  nystagmus  to  the  right  side,  then  four  ma.  with 
the  kathode  to  the  left  ear  will  produce  nystagmus  to  the  left  side  in 
the  same  patient.  The  sum  of  these  two  reactions  is  eight  ma.  Again. 
if  four  ma.  with  the  kathode  to  the  right  ear  will  produce  nystagmus  to 
the  right  side,  then  four  ma.  with  the  anode  to  the  right  ear  will  pro- 
duce nystagmus  to  the  left  side ;  the  sum  of  these  two  reactions  is  like- 
wise eight  ma.  In  the  case  of  irritative  lesion,  this  sum  is  proportion- 
ately less  than  eight  ma.  and  in  the  case  of  destruction,  proportionately 
more  than  eight  ma.  For  instance  in  case  of  an  irritative  lesion  of  the 
right  ear,  we  find  most  typically  the  reaction  to  be  approximately  as 
follows : 
Right  J  Kathode  I  ma.  rotatory  nystagmus  to  the  right  side.* 

Side  ^  Anode,  4  ma.  rotatory  nystagmus  to  the  left  side. 
Left  (  Kathode,  4  ma.  rotatory  nystagmus  to  the  left  side. 
Side  I  Anode,  I  ma.  rotatory  nystagmus  to  the  right  side. 

In  case  of  destructive  lesion  of  the  right  labyrinth,    we    find    most 
typically  the  reaction  to  be  as  follows : 
Right  f  Kathode,  8  or  more  ma.  rotatory  nystagmus  to  the  right. 

Side  |  Anode,  4  ma.,  rotatory  nystagmus  to  the  left  side. 
Left   J     Kathode,  4  ma.,  rotatory  nystagmus  to  the  left. 
Side    |    Anode,  8  or  more  ma.,  rotatory  nystagmus  to  the  right  side. 

These  results  correspond  very  closely  to  the  results  obtained  upon 
the  turning  stool,  namely : — in  case  of  one-sided  irritative  lesion 
the  sum  of  the  number  of  turnings  required  to  produce  reactions  to  the 
two  sides  is  less  than  the  sum  of  the  number  of  turnings  required  to 

"These  figures  are  more  or  less  variable,  depending  upon  the  extent  of  the 
irrhation  and  the  duration  of  the  process. 


LABYRINTH  PAPERS.  75 

produce  the  same  reactions  in  normal  people.  In  the  case  of  one-sided 
destructive  lesion  the  sum  of  the  number  of  turnings  required 
to  produce  reactions  from  the  two  sides  is  more  than  the  sum  of  the 
number  of  turnings  required  to  produce  the  same  reactions  in  normal 
people.  These  differences  are  still  greater  in  the  double-sided  than  in 
the  one-sided  affection  (irritative  and  destructive). 

In  case  of  doubt  we  have  the  other  reactions  (caloric  and  turning) 
to  help  us  to  differentiate  between  these  two  affections. 

From  my  experiments  with  the  Galvanic  reactions,  I  was  enabled  to 
conclude  that  the  Galvanic  nystagmus  is  produced  by  Galvanic  irrita- 
tion of  both  the  end  organ  in  the  ampullae  and  the  vestibular  nerve. 
In  the  case  of  labyrinth  suppuration  the  nerve  remains  more  or  less 
intact  for  a  considerable  period  of  time  (six  to  eight  weeks)  during 
which,  though  the  Galvanic  reaction  is  diminished,  it  is  not  entirely  ab- 
sent upon  the  affected  side.  This,  so  to  speak,  rest  of  Galvanic  irri- 
tability upon  the  affected  side  must  belong  to  the  nerve  alone,  since 
the  end  organs  in  the  ampullae  have  been  entirely  destroyed  by  the  sup- 
puration. This  fact  was  partly  pointed  out  first  by  Neumann,  who  suc- 
ceeded in  producing,  experimentally,  Galvanic  nystagmus  by  irritation 
of  the  exposed  stump  of  the  vestibular  nerve  in  the  wound  cavity  after 
labyrinth  operation. 

Later  I  was  able  to  corroborate  his  results  by  the  use  of  other 
methods. 

In  cases  of  acute  labyrinth  suppuration  where  the  nerve  is  still  in- 
tact, the  results  of  my  investigations  showed  that  the  Galvanic  reac- 
tions with  the  kathode  to  the  diseased  ear  required  from  eight  to  ten 
ma. ;  whereas,  in  case  of  severe  nueritis  or  atrophy  of  the  nerve  I  was 
not  able  to  obtain  the  slightest  evidence  of  a  reaction  with  as  much  as 
sixteen,  eighteen  and  twenty  ma.  (the  strongest  currents  the  patients 
could  comfortably  tolerate).  The  results  were  correspondingly  the 
same  when  the  anode  was  used,  remembering  of  course  that  the 
nystagmus  should  be  in  the  opposite  direction  to  that  produced  by  the 
kathode. 

In  the  case  of  acute  labyrinth  suppuration  where  the  nerve  is  still 
intact  a  sufficient  amount  of  current  with  the  anode  will  suppress  the 
normal  tonus  of  the  intact  nerve,  whereas  in  the  case  of  neuritis  or 
atrophy  where  there  is  no  normal  tonus  in  the  nerve,  the  anode,  with 
no  matter  how  great  a  current,  produces  no  reaction. 

I  will  not  take  up  the  space  here  to  go  into  the  details  of  the  opening 


76  DIFFERENTIATION  FROM  AFFECTIONS  OF  EIGHTH  XERJ'E. 

and  closing  nystagmi,  concerning  which  the  reader  is  referred  to  a 
paper  by  the  author  (Klinische  Studien  ueber  die  Funktionspriifung 
des  Labyrinthes  mittels  des  galvanischen  Stromes,  Archiv.  f.  Orhen- 
heilk,  Bd.  78.  1908).  I  will  merely  mention  here  a  few  of  the  more 
essential  facts,  (i)  In  normal  people  with  the  kathode  to  the  ear, 
upon  closing  the  current  there  is  a  nystagmus  to  that  side;  (2)  upon 
breaking  the  current,  there  is  a  nystagmus  to  the  opposite  side  of 
equal  intensity  to  the  closing  nystagmus;  (3)  with  the  anode  to  the 
ear,  upon  closing  the  current  there  is  a  nystagmus  to  the  opposite 
side;  and  (4)  upon  breaking  the  current,  there  is  a  nystagmus  to  the 
same  side  of  equal  intensity  to  the  closing  nystagmus ;  therefore, 
KCN  =  KONandACN  =  AON.  Deviations  from  these 
normal  conditions  indicate  pathologic  conditions.  For  illustration:  in 
case  of  right-sided  labyrinth  suppuration,  we  have : 
Right  JKCN<KON  Left  (KCN>KON 

Side  JACN>AON  side  t  ACN<AON 

In  the  case  of  complete  neuritis  or  atrophy  of  the  nerve  of  the  right 
side  and  in  case  of  secondary  degeneration  following  labyrinth  sup- 
puration we  have : 

Right  I  K  C  N  and  K  O  N  negative    Left     f  K  C  N  >  K  O  N 
Side    (  A  C  N  and  A  O  N  negative       Side  \  A  C  N  <  A  O  N 

In  considering  the  differential  diagnosis  of  labyrinth  suppuration 
from  neuritis,  the  history  and  the  otoscopic  findings  afford  us  great 
aid.  In  labyrinth  suppuration  we  have  the  positive  history  and 
otoscopic  findings  of  middle  ear  suppuration,  while  in  neuritis  these 
are  negative  excepting  in  the  rarest  cases,  where  middle  ear  suppura- 
tion may  be  coincidently  present.  On  the  contrary,  in  the  case  of 
neuritis  we  are  generally  able  to  obtain  a  history  pointing  to  one  of  the 
previously  mentioned  causes  (infectious,  constitutional  or  toxic). 

In  case  of  neuritis  complete  involvement  of  all  branches  of  the  eighth 
nerve  is  the  exception  rather  than  the  rule.  It  frequently  happens  that 
the  cochlear  branch  is  more  involved  than  the  vestibular  branch,  and 
vice  versa. 

In  neuritis  it  frequently  happens  that  the  involvement  of  the  eighth 
nerve  is  but  one  of  the  manifestations  of  a  polyneuritis ;  in  which  cases 
we  are  often  able  to  detect  pareses,  (though  often  but  slight),  of  one 
or  more  of  the  other  cranial  nerves. 

In  case  of  neuritis  the  affection  is  frequently  bilateral,  as  elsewhere 
pointed  out.  The  bilateral  form  occurs  especially  frequently  from  toxic 


LABYRINTH  PAPERS. 


77 


causes.  A  bilateral  aeffction  points  decidedly  to  neuritis  rather  than 
to  labyrinth  suppuration. 

From  the  foregoing  we  see  that  the  greatest  difficulty  to  be  met  with 
in  the  differential  diagnosis  occurs  in  the  case  of  unilateral  isolated 
complete  neuritis  of  the  eighth  nerve  with  complete  loss  of  both  acoustic 
and  static  functions ;  fortunately,  these  are  the  rarest  cases  we  meet, 
and  in  these  cases  the  Galvanic  reactions  (see  above)  should  determine 
the  diagnosis. 

In  closing  the  subject,  let  us  summarize  briefly  the  more  important 
differential  symptoms  and  signs  of  these  two  processes. 


LABYRINTH   SUPPURATION. 

I — Positive  history  of  middle 
ear  suppuration,  together  with 
the  history  of  previous  attacks 
of  vertigo  from  labyrinth  hy- 
peraemia  or  labyrmthitis 
serosa. 

2 — Otoscopic  findings  character- 
istic for  middle  ear  suppura- 
tion (secretion,  perforation, 
polyps,  cholesteatoma,  etc.). 


3  —  Tinnitus     and 
noises  negative. 


subjective 


4 — Deafness  is  absolute. 


NEURITIS  OF  EIGHTH   NERVE. 

I — Negative  history  of  -middle 
ear  suppuration ;  but  on  the 
contrary  history  of  infectious 
disease,  or  some  toxic  poison- 
ing (quinine,  salicylates,  al- 
cohol, tobacco,  etc.)  ;  or  ex- 
posure to  cold  and  moisture. 

2 — Otoscopic  findings  negative 
except  in  cases  of  herpes 
zoster  involving  the  membrana 
tympani  (see  above),  but  in 
these  cases  we  are  usually 
able  to  detect  the  herpes  blebs 
elsewhere  in  the  region  of  the 
external  ear  and  frequently  on 
the  auricle. 

3  —  Tinnitus  and  subjective 
noises  usually  positive,  and 
they  last  for  indefinite  periods 
of  time  from  few  hours  to 
several  weeks;  in  rare  cases, 
followed  by  atrophy,  even 
longer. 

4 — Deafness  may  be  absolute  or 
partial,  and  the  type  of  this 
deafness  is  characteristic  of 
that  found  in  diseases  of  the 
perceiving  apparatus. 


78  DIFFERENTIATION  FROM  AFFECTIONS  OF  EIGHTH  NERl'E. 


LAP.VRINTH    SUPPURATION" Coil- 

ti  nued. 

5 — Intense  vertigo  lasting  from 
three  to  five  days,  less  pro- 
nounced for  a  few  weeks  long- 
er during  rapid  movements  of 
the  head. 

6 — Equilibrium  disturbances  of 
the  so-called  vestibular  type. 

7 — Spontaneous  rotatory  nystag- 
mus to  the  sound  side. 

8 — Negative  caloric  irritability 
of  the  static  labyrinth. 

9 — Shortened  duration  of  the 
after-nystagmus  to  the  dis- 
eased side. 

10 — Galvanic  reactions  in  recent 
cases  only  show  the  following 
average  findings : 

Kathode,    7    ma.,    rot. 

Right          nys>  to  r. 

Side        Anode,  3  ma.,  rot.  nys. 

to  1. 
Kathode,    3    ma.,    rot. 

Left  n.vs-  to  1- 

Side  Anode,  7  ma.,  rot.  nys. 
to  r. 

II — Paresis  of  other  cranial 
nerves  the  exception,  and  then 
only  the  seventh  nerve. 

12 — Unilateral  involvement. 

13 — Permanent  loss  of  both 
acoustic  and  static  functions. 


NEURITIS     OF     EIGHTH     NERVE. 

Continued. 

5 — Intense  vertigo  lasting  as  a 
rule  longer  than  in  the  case  of 
labyrinth  suppuration. 


6 — Same  as  in  labyrinth  sup- 
puration. 

7 — Same  as  in  labyrinth  sup- 
puration. 

8 — Same  as  in  labyrinth  sup- 
puration. 

9 — Same  as  in  labyrinth  sup- 
puration. 

10 — Galvanic  reactions  show  the 
following  average  findings : 

Kathode,  18  ma.,  no  re- 
Right          action. 
Side        Anode,    18  ma.,    no   re- 
action. 

Kathode.    3     ma.,     rot. 
Left  nys.  to  1. 

Side        Anode,   18  ma.,  no  re- 
action. 

II — Paresis  of  other  cranial 
nerves,  more  frequently  the 
II,  V,  VII,  XII ;  however,  any 
of  the  others  may  be  involved. 
12 — Frequently  bilateral  involve- 
ment. 

13 — In  the  majority  of  cases  the 
prognosis  is  favorable  with 
ultimate  recovery  of  both 
acoustic  and  static  functions. 


PROGNOSIS  AND  TREATMENT  OF  LABYRINTH 
SUPPURATION 

GREATER  attention  has  been  paid  to  the  operative  treatment  of 
labyrinthine  infections  than  to  their  diagnosis  and  differentia- 
tions.   Originally  the  determination  of  the  operative  proced- 
ure upon  the  labyrinth  was  decided  by  the  findings  at  the  time  of  the 
radical  mastoid  operation.    This  form  of  practice  mighf.  have  done  well 
enough  for  the  past  but  not  for  the  present. 

Since  the  adoption  of  exact  examination  methods  the  normal  physi- 
ologic functions  of  the  labyrinth  have  been  ascertained  and  at  present 
we  are  able  to  determine,  from  variations  in  or  by  absence  of  these 
functions,  pathologic  conditions  of  the  labyrinth.  As  a  result,  the  best 
operators  are  adopting  the  plan  of  determining  the  exact  condition 
of  the  labyrinth  before  performing  any  operation  upon  the  ear. 

It  must  not  be  forgotten  that  the  best  results  are  obtained  not  by  the 
ability  to  operate  alone  but  by  the  combination  of  this  ability  with  a 
knowledge  of  the  diagnosis ;  I  might  go  further  and  say  that  the  prog- 
nosis and  treatment  are  entirely  dependent  upon  the  diagnosis. 

The  primary  object  of  many  operators  has  been  to  perform  the 
labyrinth  operations  without  a  sufficient  knowledge  of  the  diagnosis 
and  indications.  This  condition  has  been  fruitful  however  in  bringing 
about  at  least  one  result,  namely,  the  perfection  of  the  operations  and  a 
high  development  of  surgical  technique. 

Many  excellent  papers  have  been  written  upon  the  surgical  treatment 
of  labyrinthine  infections,  including  the  recent  one  by  Richards,  of 
New  York  (Laryngoscope,  Oct.,  1907),  and  the  still  more  recent  one 
by  Albert  Jansen  (Annals  of  Otol.,  Rhin.  and  Laryng.,  June,  1908), 
however  both  authors  in  their  respective  papers  show  a  lack  of  knowl- 
edge of  the  diagnosis  and  indications  for  treatment.  Had  they  given 
mdre  attention  to  the  subject  of  diagnosis  and  the  methods  of  examina- 
tion, or  had  they  familiarized  themselves  with  the  work  of  Barany 
(Phys.  und  Path,  des  Bogc-ng.  . \ppar.  beim  Menchen),  these  men 
would  have  made  fewer  misstatements  concerning  the  diagnosis,  prog- 
nosis and  indications  for  treatment. 

Is  it  any  wonder  that  Jansen's  postoperative  mortality  (Annals  of 
O.,  R.  and  L.,  1908,  page  367),  25  per  cent.,  should  have  been  so  high 


8o  PROGNOSIS  AND   T  RE  ATM  EXT. 

as  compared  with  Hinsberg's,  4  per  cent,  (furnished  by  Freytag,  Z. 
f.  O.,  Bd.  51,  page  341)?  The  explanation  is  that  Hinsberg  under- 
stood the  diagnosis  and  operated  when  operation  was  indicated,  while 
Jansen,  who  did  not  understand  the  diagnosis  as  well,  operated  hit  or 
miss  style,  with  the  result  that  many  labyrinths  were  sacrificed  and 
lives  risked  if  not  lost  that  might  have  been  saved  by  more  conservative 
treatment. 

After  having  carefully  read  Jansen's  paper  upon  the  "Treatment  of 
Infective  Labyrinthitis/'  I  wish  to  protest  forcibly  against  his  mis- 
statements  concerning  the  diagnosis  and  indications  for  operation,  be- 
cause of  the  great  danger  of  misleading  some — fortunately  not  all — of 
the  American  otologists  who  may  be  inclined  to  accept  his  statements 
as  authoritative. 

Had  Jansen  familiarized  himself  more  with  what  Barany  and  N^u- 
mann  had  done,  rather  than  attempt  to  take  from  them  the  credit  they 
deserve,  he  certainly  would  have  known  more  about  the  diagnosis  of 
labyrinthitis  and  the  indications  for  operation  than  he  manifested  in  his 
jumble  of  misstatements.  On  the  other  hand,  Jansen  deserves  great 
credit  for  having  inaugurated  and  helped  to  perfect  the  labyrinth 
operations. 

In  considering  the  prognosis  and  treatment  of  labyrinth  suppuration 
it  will  be  necessary  at  the  same  time  to  consider  the  prognosis  and 
treatment  of  the  other  pathologic  conditions  of  the  labyrinth.  These 
conditions  will  be  considered  separately. 

I.  Hyperemia  of  the.  Labyrinth.  Passive  hyperemia 
will  not  be  considered  here  since  it  does  not  occur  as  a  result  of  acute  or 
chronic  middle  ear  suppuration ;  while  on  the  other  hand,  active  hyper- 
emia does  (see  former  paper  upon  differential  diagnosis). 

The  prognosis  in  active  hyperemia  of  acute  middle  ear  inflammation 
or  suppuration  is  generally  favorable,  the  hyperemia  terminating  in 
resolution.  In  exceptionally  rare  cases  the  hyperemia  is  but  the  initial 
stage  of  suppuration ;  in  this  latter  instance  the  prognosis  is  generally 
unfavorable  to  the  functions  and  to  life,  death  occurring  in  from  one  to 
a  few  days  from  a  suppurative  meningitis  due  as  a  rule  to  very  virulent 
streptococcic  infection. 

The  treatment  of  hyperemia  of  the  labyrinth  with  acute  middle  ear 
inflammation  should  be  the  prompt  evacuation  of  the  middle  ear  by  a 
free  paracentesis  or  the  enlargement  of  a  too  small  perforation,  the 
application  of  drainage  gauze  into  the  external  canal  and  moist  heat, 


LABYRINTH  PAPERS.  8r 

absolute  rest  in  bed  and  the  administration  of  the  indicated  remedy.  In 
the  event  of  a  serious  turn  in  those  rare  cases  mentioned  with  begin- 
ning meningeal  symptoms  the  labyrinth  operation  should  be  performed 
early. 

The  prognosis  in  the  hyperemia  of  chronic  middle  ear  inflammation 
is  even  more  favorable  than  in  those  cases  occurring  with  acute  middle 
ear  inflammation.  Since  here  we  have  generally  a  perforation  of  the 
tympanic  membrane  of  considerable  size  we  are  denied  the  opportunity 
of  making  or  enlarging  the  perforation.  In  these  cases  there  is  usually 
an  acute  exacerbation  of  the  chronic  middle  ear  suppuration  or  reten- 
tion of  secretion  in  one  of  the  accessory  cavities  with  adhesive  bands, 
polyps  or  cholesteatoma. 

The  treatment  should  be  directed  toward  the  cause ;  in  the  event  of 
?,n  acute  exascerbation  of  the  chronic  middle  ear  suppuration  con- 
servative treatment  with  rest  in  bed  is  generally  sufficient.  In  the  case 
of  retention  with  polyps  or  cholesteatoma,  these  alone  would  give  an 
indication  for  the  radical  operation,  but  not  during  the  attack  if  it  can 
be  postponed  for  fear  of  precipitating  an  actual  inflammation  of  the 
labyrinth ;  in  these  cases  it  would  be  better  to  operate  between  the  at- 
tacks. In  rare  cases  the  hyperemia,  as  in  the  case  of  hyperemia  of  acute 
inflammation  of  the  middle  ear,  might  be  the  preliminary  stage  of  a 
labyrinthitis,  in  which  event  the  case  must  be  treated  accordingly. 

II.  Acute  Diffuse  Serous  Labyrinthitis.  Since 
the  differential  diagnosis  of  this  condition  from  labyrinth  suppuration 
is  somewhat  difficult ;  and  furthermore  since  no  exact  statistics  have 
been  made,  we  are  unable  to  say  what  per  cent,  of  serous  labyrinthitis 
recovers  spontaneously  and  what  per  cent,  terminates  either  in  acute 
labyrinth  suppuration  or  chronic  labyrinthitis  with  new  formed  con- 
nective tissue  and  destroyed  end  organs.  Fortunately  however  the 
prognosis  in  many  of  the  cases,  under  proper  treatment,  is  favorable 
both  to  function  and  to  life. 

The  treatment  during  the  attack  should  be  both  conservative  and 
expectant;  it  is  especially  in  these  cases  that  waiting  is  profitable. 
There  has  been  a  tendency  to  commit  one  of  two  errors  ;  either  to  do  the 
radical  mastoid  operation  immediately,  with  the  result  that  the  serous 
labyrinthitis  develops  into  a  suppurative  labyrinthitis,  or  to  operate  the 
case  as  one  of  suppurative  labyrinthitis  with  the  result  of  permanent 
destruction  of  the  functions.  It  would  be  far  better  after  having 
first  determined  the  diagnosis  of  serous  labyrinthitis  (see  paper  on 
6 


82  PROGNOSIS  AND  TREATMENT. 

differential  diagnosis)  to  put  the  patient  to  bed,  insert  drainage  gauze 
into  the  canal,  one  end  of  which  is  introduced  into  the  middle  ear 
cavity,  changing  the  gauze  as  often  as  necessary,  and  administer  the 
indicated  internal  remedy.  Such  treatment  will  in  the  majority  of 
cases  result  in  recovery. 

It  is  a  mistake  to  attempt  any  manipulation  or  instrumentation  of  the 
middle  ear  during  an  attack  of  serous  labyrinthitis.  In  order  to  prevent 
a  recurrence  or  a  subsequent  attack  of  suppurative  labyrinthitis  we 
should  immediately,  after  the  attack  of  serous  labyrinthitis  has  passed 
over,  perform  the  radical  mastoid  operation  and  eliminate  all  infecting 
foci  within  the  middle  ear  spaces. 

III.  Circumscribed      Irritative      Lesion     of     the 
Labyrinth.    The  prognosis  in  this  condition  is  even  more  favorable 
under  proper  treatment  than  that  of  serous  labyrinthitis,  and  the  same 
remarks  concerning  the  prognosis  and  treatment  of  diffuse  serous  laby- 
rinthitis apply  to  this  condition. 

IV.  Circumscribed    Destructive    Lesion    of    the 
Labyrinth.    Since  circumscribed  destructive  lesions  of  the  mem- 
branous labyrinth  are  usually  combined  with  similar  changes  of  the 
bony  labyrinth  (labyrinth  capsule)  we  shall  speak  of  them  together. 
Circumscribed  destructive  lesions  of  the  membranous  labyrinth  are 
usually  in  the  form  of  suppurations  or  granulations  with  surrounding 
zones   of   inflammatory   reaction   limiting   the    destructive   pathologic 
changes  to  the  circumscribed  area.    Later,  in  the  surrounding  zone  of 
inflammation,  adhesions  are  formed  which  serve  as  a  barrier  to  the 
spreading  of  the  infection. 

The  changes  in  the  labyrinth  capsule  are  in  the  form  of  fistulae, 
erosions,  caries  and  necrosis. 

The  prognosis  is  dependent  upon  the  location.  When  the  lesion  is  in 
the  region  of  the  semicircular  canals  (more  often  horizontal)  the  prog- 
nosis is  more  favorable  than  when  in  the  region  of  the  oval  window  or 
promontory,  since  in  the  former  instance  the  canals  being  narrow, 
lumened  tubes  the  adhesions  can  better  shut  off  the  infection  from 
spreading  than  in  the  case  of  the  vestibule  or  cochlea,  where  the  laby- 
rinth opens  into  wider  spaces. 

The  prognosis  too  is  dependent  upon  the  treatment.  The  circum- 
scribed destructive  lesions  of  the  labyrinth  are  usually  slower  processes 
than  the  diffuse  serous  or  suppurative  forms,  as  a  result  we  have  more 
time  to  consider  our  cases  and  the  form  of  treatment  to  be  applied  In 


LABYRINTH  PAPERS.  {;3 

the  event  of  neglect  of  treatment  there  is  the  constant  danger  of  slow  or 
rapid  progress  of  the  circumscribed  destructive  process  with  the  result 
eventually  of  an  acute  diffuse  suppurative  labyrinthitis.  Realizing  the 
dangers  of  a  circumscribed  destructive  lesion,  we  should  institute  our 
treatment  as  soon  as  the  diagnosis  is  determined. 

The  treatment  consists  of  the  radical  mastoid  operation  and  the  ex- 
posure of  the  lateral  labyrinth  wall  to  full  inspection.  We  should  then 
eliminate,  as  thoroly  as  possible,  all  cholesteatomatous  masses,  granula- 
tions, necrotic  bone,  etc.,  using  every  precaution  not  to  stir  up  the  condi- 
tion in  the  labyrinth  for  fear  of  breaking  the  adhesions,  which  may  have 
formed,  and  thus  favor  an  extension  of  the  suppuration.  This  can  be 
more  readily  accomplished  in  the  case  of  a  circumscribed  destructive 
lesion  of  the  horizontal  semicircular  canal  than  in  a  case  of  lesion  about 
the  oval  or  round  windows  or  the  promontory.  In  the  latter  cases 
(circumscribed  destructive  lesion  about  the  windows  or  promontory) 
the  danger  of  the  conservative  operation  is  too  great,  besides  since  the 
hearing  is  almost  if  not  entirely  destroyed  we  have  not  the  same  in- 
centive to  try  the  conservative  operation.  In  these  cases  one  of  the 
more  radical  labyrinth  operations  should  be  performed. 

V.  Perilabyrinthitis  with  partial  or  complete 
sequestration  of  the  labyrinth  capsule. 

The  prognosis  depends  ( i )  upon  the  extent  and  acuteness  of  the  pro- 
cess; (2)  upon  the  nature  of  the  predisposing  cause  (tuberculosis, 
diabetes,  syphilis,  scarlatina,  etc)  ;  (3)  upon  the  treatment,  the  prompt- 
ness with  which  we  get  at  it  and  the  thoroness  of  the  operation. 

In  all  cases  with  complete  sequestration  of  the  labyrinth  capsule  there 
is  facial  paralysis.  On  the  other  hand,  in  case's  of  partial  sequestration, 
especially  when  limited  to  the  cochlea,  the  facial  canal  may  escape  in- 
volvement. 

In  some  cases  the  entire  labyrinth  has  been  thrown  off  piece  by  piece 
thru  the  external  canal  without  any  untoward  result ;  in  other  cases 
operative  interference  may  be  necessary.  The  prognosis  to  the  func- 
tions is  bad,  but  to* life  generally  good.  There  is  less  tendency  to  intra- 
cranial  complications  in  perilabyrinthitis  than  in  labyrinth  suppuration  ; 
however,  complications  do  occur  in  exceptional  cases,  but  in  these  the 
predisposing  cause  plays  a  role.  In  the  cases  of  complete  sequestra- 
tion facial  paralysis  is  complete  and  permanent,  the  only  hope  for 
future  function  lies  in  the  performance  of  one  of  the  nerve  anastomo- 
ses operations. 


84  PROGNOSIS  A\'D  TREAT  M  EXT. 

The  treatment  should  be  at  first  prophylactic.  In  other  words,  all 
cases  of  mastoiditis  in  the  course  of  acute  or  chronic  middle  ear  sup- 
puration should  be  operated  promptly,  following  up  the  pus  until 
normal  tissue  is  reached.  If  this  were  done  in  every  case,  especially 
those  showing  early  involvement  of  the  facial  nerve,  there  would  be 
fewer  cases  of  labyrinth  sequestration.  The  simple  mastoid  operation 
in  acute  cases  and  the  radical  Kuester-Bergmann  mastoid  operation  in 
chronic  cases,  including  the  removal  of  the  mastoid  tip,  if  done  and  done 
early  will  be  sufficient  to  limit  most  cases  of  perilabyrinthitis.  In  the 
cases  well  advanced,  after  sequestration  has  taken  place,  the  above 
mentioned  operations  are  insufficient.  In  this  event  we  must  perform 
in  addition  to  the  mastoid  operation  an  operation  for  the  removal  of 
the  sequestered  part  or  whole  of  the  labyrinth,  which  will  be  found  ly- 
ing imbedded  loosely  in  a  dark  granular  mass  of  debris  and  pus,  from 
which  it  can  be  removed  easily  with  the  anatomical  forceps.  This 
should  be  followed  by  thoro  curettement  of  all  diseased  tissue. 

Aside  from  the  operative  treatment  it  is  well  to  direct  sanitary  and 
internal  treatment  toward  the  predisposing  causes,  to  aid  the  after 
healing,  which  tends  to  be  very  slow  in  these  cases. 

VI.  Suppurative  Labyrinthitis  (labyrinth  suppura- 
tion). The  prognosis  in  this  condition  would  seem  to  vary  with  the 
skill  of  the  diagnostician.  It  is  almost  impossible  to  compute  the  mor- 
tality, since  in  one  clinic  all  cases  of  labyrinth  infections  are  grouped 
together  in  one  class,  while  in  a  second  clinic  the  diagnoses  are  so 
loosely  made  that  the  figures  become  unreliable.  For  instance  Jansen 
in  his  statistics  includes  cases  which  are  positively  not  those  of  laby- 
rinth suppuration,  as  does  also  Herzog.  Herzog  (Labyrintheiterung 
und  Gehor,  1907)  reports  three  cases  (Nos.  3,  4,  5)  among  a  total  of 
seven  in  which  the  labyrinth  suppuration  was  double-sided.  Altho 
double-sided  labyrinth  suppuration  is  possible,  that  so  high  a  per- 
centage of  such  cases  occurring  in  one  man's  experience  seems  highly 
improbable,  especially  when  we  recall  the  fact  that  such  authorities  as 
Hinsberg,  Alexander,  Neumann  and  Barany  have  failed  to  locate  a 
single  case  during  the  last  five  years. 

All  authors  agree,  however,  that  the  prognosis  is  generally  unfavor- 
able in  untreated  acute  labyrinth  suppuration,  and  much  worse  in  cases 
maltreated;  from  which  we  may  safely  conclude  that  it  is  safer  to 
leave  the  case  to  itself  than  to  treat  it  improperly. 

In  the  first  place  the  prognosis  for  both  acoustic  and  static  functions 


LABYRINTH  PAPERS.  85 

is  invariably  unfavorable;  next  the  prognosis  to  life  is  rather  un- 
favorable in  the  untreated  cases,  the  infection  finding  its  way  into  the 
brain — (i)  thru  the  internal  auditory  canal,  resulting  in  a  circum- 
scribed or  diffuse  serous  or  suppurative  meningitis;  (2)  thru  the  aque- 
ductus  cochleae,  resulting  in  a  circumscribed  or  diffuse  serous  or  sup- 
purative leptomeningitis ;  (3)  thru  the  aqueductus  vestibuli,  resulting 
either  in  an  interdural  (saccus  empyema),  deep  extradural,  subdural  or 
cerebellar  abscess.  Altho  the  above  results  are  the  rule,  exceptions  do 
exist ;  in  these  exceptional  cases  two  or  more  conditions  may  occur  coin- 
cidentally  thru  two  separate  routes  of  invasion ;  for  instance,  from  an 
acute  infection  of  an  old  cholesteatoma  simultaneous  infection  of  the 
middle  and  posterior  cranial  fossae  with  labyrinth  suppuration  may  take 
place.  In  simple  labyrinth  suppuration  the  intra-cranial  infection  rarely 
takes  place  thru  any  but  the  preformed  ways,  for  the  reason  that  the 
infection  tends  to  follow  the  line  of  least  resistance. 

The  cases  which  terminate  favorably  are  those  where  the  suppura- 
tion limits  itself  to  the  labyrinth ;  the  process  of  limitation  of  the  sup- 
puration taking  place  as  a  result  of  closure  of  the  orifices  of  communi- 
cation to  the  brain  (internal  auditory  canal,  aqueductus  cochleae  and 
aqueductus  vestibuli)  thru  a  serofibrinous  inflammation,  produced 
probably  by  the  toxins  of  the  infection  and  not  the  infection  itself  in  a 
manner  similar  to  the  limitation  of  suppuration  to  the  bulbus  in  case  of 
panophthalmitis.  This  favorable  result  occurs  in  both  instances  (sup- 
purative panotitis  and  suppurative  panophthalmitis),  especially  when 
treatment  has  been  expectant  and  conservative  with  absolute  rest  in  bed 
and  as  little  local  interference  as  possible  combined  with  the  indicated 
internal  remedy. 

The  indications  for  the  labyrinth  operation  are  not  prompted  by  the 
labyrinth  suppuration  alone,  but  too  by  the  meningeal  irritation  or  in- 
flammation and  the  primary  middle  ear  suppuration. 

Since  it  is  dangerous  to  perform  a  radical  operation  in  cases  of  laby- 
rinth suppuration  without  at  the  same  time  opening  or  removing  a 
sufficient  part  of  the  labyrinth  for  the  purpose  of  drainage,  we  are  com- 
pelled to  do  the  complete  operation.  There  are  cases  of  very  late  laby- 
rinth suppuration  which  have  spent  themselves  within  the  labyrinth 
where  a  radical  operation  alone  may  be  sufficient.  However,  I  agree 
with  Barany  that  such  a  procedure  is  rather  dangerous,  for  the  reason 
that  we  can  never  tell  positively  just  how  securely  the  suppurative  pro- 
cess is  shut  in  the  labyrinth  by  the  connective  tissue  adhesions  about  the 


86  PROGNOSIS  AXD  TREATMENT. 

orifices,  and  if  the  adhesions  are  at  all  insecure  the  traumatism  of  the 
operation  will  rupture  them  with  the  result  of  a  rapidly  developing 
diffuse  suppurative  labyrinthitis. 

The  prognosis  after  the  labyrinth  operation  is  quite  favorable,  the 
mortality  being  from  4  per  cent.  (Hinsberg)  to  25  per  cent.  (Janscn). 
The  mortality  in  the  Politzer  and  the  Alexander  clinics  corresponds 
roughly  with  that  of  Hinsberg's. 

The  treatment  of  labyrinth  suppuration  may  be  conservative  or  radi- 
cal. The  conservative  treatment  is  indicated  first  in  those  cases  where  in 
spite  of  the  continuance  of  the  symptoms  and  signs  of  lost  acoustic  and 
static  functions,  the  headache,  slight  fever,  the  slight  choking  of  the 
discs  or  overfilling  of  veins,  gradually  diminish ;  or  in  those  late  cases 
where  from  the  lack  of  headache  and  fever  and  with  normal  fundus 
findings  we  have  reason  to  believe  that  the  diseased  condition  Ins  be- 
come limited  to  the  labyrinth. 

When  we  have  decided  upon  the  conservative  treatment  it  is  best  to 
put  the  patient  to  bed,  use  simple  drainage  gauze,  and  give  the  indicat- 
ed internal  remedy.  It  will  be  surprising  what  excellent  results  may  be 
obtained  in  selected  cases  by  such  simple  treatment.  Personally  how- 
ever I  am  somewhat  too  timid  to  rely  upon  this  treatment ;  knowing  that 
a  subsequent  radical  must  be  performed  and  the  dangers  it  will  invite, 
and  furthermore  believing  that  the  labyrinth  suppuration  indicates  a 
severe  form  of  middle  ear  suppuration  which  may  later  give  rise  to 
other  intracranial  complications  (sinus  phlebitis,  meningitis,  extradural, 
cerebellar  or  temporal  lobe  abscess)  I  prefer  to  rely  upon  the  radical 
treatment. 

The  radical  treatment  of  labyrinth  suppuration  consists  first  in  the 
performance  of  the  Kuester-Bergmann  radical  operation,  including 
complete  evacuation  of  the  mastoid  process  and  removal  of  the  tip. 
Good  illumination  is  a  prerequisite,  best  accomplished  by  the  use  of  an 
Alexander  electric  head  mirror  (obtainable  from  Meyrowitz,  of  New 
York).  From  this  step  we  have  a  choice  of  three  methods  for  per- 
forming the  operation  upon  the  labyrinth ;  namely,  the  original  method 
of  Jansen,  the  method  of  Hinsberg  and  the  method  of  Neumann. 

JANSEN'S  TYMPANIC  OR  SEMICIRCULAR  CANAL  METHOD. 

Jansen  has  employed  this  first  method  since  1893.  He  begins  by  re- 
moving the  upper  wall  of  the  anterior  crus  of  the  horizontal  semicircu- 


LABYRINTH  PAPERS.  87 

lar  canal,  allowing  the  lower  wall  to  remain  for  the  double  purpose  of 
serving  as  a  protection  against  injury  to  the  facial  canal  and  for  sub- 
sequent orientation.  This  trick  is  practiced  also  by  Neumann,  and 
both  men  claim  the  credit  for  having  originated  the  idea.  The  pos- 
terior crus  of  the  horizontal  canal  is  then  removed  in  its  entirety.  He 
next  removes  the  bone  below  and  backward  from  this  part  of  the  hori- 
zontal canal,  taking  care  to  avoid  the  facial  canal.  He  then  opens  the 
posterior  wall  of  the  vestibule  between  the  ampullar  and  smooth  ends 
of  the  horizontal  canal.  To  accomplish  this  with  the  least  danger  of 
injury  to  neighboring  parts  the  chisel  should  be  applied  with  the  con- 
cavity externally  when  chiseling  from  the  posterior  crus  into  the  vesti- 
bule and  vice  versa  when  chiseling  from  the  anterior  crus  medianward, 
at  the  same  time  taking  care  to  avoid  the  facial  canal.  He  varies  his 
method  somewhat  according  to  the  pathologic  changes  found  at  the 
time  of  operation  (the  presence  or  absence  of  fistula). 

After  opening  the  posterior  wall  of  the  vestibule  the  anterior  wall  is 
sought.  In  determining  the  location  of  the  anterior  wall  Jansen  does 
not  depend  entirely  upon  the  anterior  crus  of  the  horizontal  canal  but 
also  upon  the  location  of  the  oval  window  which  he  determines  by  the 
use  of  the  bent  probe  introduced  into  the  cavity  of  the  vestibule. 

Jansen  feels  that  the  exposure  of  the  anterior  wall  is  imperative  in 
those  cases  of  narrowing  of  the  vestibule  with  new  formation  of  bone. 
After  determining  the  exact  location  of  the  lateral  wall  of  the  vestibule 
by  thoro  sounding  with  the  probe  within  the  cavity  of  the  vestibule,  he 
then  removes  it  with  great  care  with  either  a  narrow  chisel  or  burr. 
He  prefers  the  use  of  the  chisel  when  he  wishes  to  ascertain  a  knowl- 
edge of  the  vestibule  contents,  otherwise  he  prefers  the  use  of  the  burr. 
He  advises  the  use  of  the  burr  too  especially  to  preserve  the  facial  canal 
and  the  inferior  wall  of  the  anterior  crus  of  the  horizontal  canal.  He 
advises  us  of  the  importance  of  reaching  the  deepest  point  in  the  vesti- 
bule, laying  bare  its  floor.  He  next  enlarges  the  cavity  of  the  vestibule 
downward  by  exposing  the  lower  orifice  of  the  inferior  semicircular 
canal  and  enlarges  it  backward  by  exposing  the  common  orifice  of  the 
vertical  canals.  He  advises  the  use  of  the  burr  in  enlarging  the  cavity 
backward.  He  finally  exposes  the  ampulla  of  the  superior  semicircular 
canal.  Rarely  does  he  follow  up  all  of  the  canals.  He  cautions  against 
too  vigorous  enlargement  of  the  oval  window  backward  on  account  of 
the  danger  of  narrowing  the  bridge  of  bone  containing  the  facial  nerve 
to  the  extent  that  necrosis  may  follow. 


88  PROGNOSIS  AXD  TREATMENT. 

Jansen  claims  that  this  operation  is  the  safest  and  fraught  with  the 
least  danger  to  life.  He  does  not  consider  the  operation  upon  the 
cochlea  as  always  necessary ;  however,  when  he  does  deem  it  necessary 
he  recommends  the  following  method : 

OPERATION  UPON  THE  COCHLEA. 

Jansen  has  modified  his  former  method  of  complete  removal  of  the 
cochlea  to  that  of  removal  of  the  promontory  and  the  exposure  of  the 
lower  cochlear  whorl  only,  at  the  same  time  avoiding  injury  to  the 
modiolus.  He  has  avoided  injury  to  the  modiolus  since  having  lost  at 
least  one  case  by  such  injury  with  a  probe.  On  the  other  hand,  when 
the  cochlea  is  transformed  into  a  sequestrum  lying  in  a  bed  of  granula- 
tions and  pus  he  effects  its  removal  with  the  gouge. 

THE  HINSBERG   METHOD. 

The  first  step  in  this  method  is  to  perform  the  complete  radical  opera- 
tion, including  the  removal  of  the  posterior  wall  of  the  external  canal 
downward  to  the  level  of  the  floor  of  the  canal  and  the  shaving  down 
of  the  facial  spur  as  far  as  possible  without  injury  to  the  nerve,  thus 
permitting  the  best  possible  inspection  of  the  region  of  the  oval  window, 
the  facial  canal  and  the  prominence  of  the  horizontal  semicircular  canal. 
He  next  seeks  the  oval  window.  If  the  stapes  is  still  there  he  removes 
it,  then  with  the  very  small  bone  forceps  of  Bourquet  introduced  into 
the  oval  window  he  proceeds  to  remove  the  lateral  vestibular  wall  to  the 
round  window  and  at  the  same  time  opens  the  lower  cochlear  whorl ; 
he  then  lays  the  bone  forceps  aside  and  proceeds  to  remove  the  promon- 
tory anteriorly  using  the  chisel,  which  he  prefers  to  the  burr  since  he 
can  keep  a  clearer  field,  the  burr  producing  too  much  bone  dust  and 
thereby  obscures  the  field.  He,  like  Jansen,  is  very  careful  not  to 
work  backward  toward  the  facial.  Hinsberg  then  introduces  a  bent 
probe,  or  better,  the  Bourquet  facial  nerve  protector,  into  the  enlarged 
opening,  carrying  it  backward  and  slightly  upward  behind  the  facial 
until  its  tip  reaches  the  anterior  crus  of  the  horizontal  canal,  which  he 
then  proceeds  to  remove  with  the  Bourquet  forceps.  He  completes  his 
operation  according  to  the  findings,  by  opening  or  not  the  remaining 
canals. 

Hinsberg  like  Jansen  deviates  from  his  routine  course  in  case  of 
fistula.  In  the  event  of  previously  long  standing  facial  paralysis  with 
cholesteatomatous  invasion  of  the  labyrinth,  where  oftimes  the  facial 


LABYRINTH  PAPERS.  89 

canal  has  been  eroded  and  the  nerve  more  or  less  destroyed,  he  does  not 
spare  the  facial  canal  but  proceeds  directly  to  remove  it,  trusting  to  a 
subsequent  facial  nerve  anastomosis  rather  than  to  the  dangers  invited 
by  a  less  radical  procedure. 

THE   NEUMANN    ENDOCRANIAL   METHOD, 

Is  a  modified  and  improved  endocranial  method  of  Jansen  which  he 
(Jansen)  claims  to  have  performed  as  early  as  1895,  m  cases  of  deep 
extradural  abscess.  Jansen  has  since  abandoned  this  method  more  or 
less  because,  as  he  claims,  it  is  a  more  difficult  and  dangerous  procedure 
than  his  socalled  "tympanic  method." 

The  operation  as  Neumann  performs  it  consists  first  in  performing 
the  most  complete  radical  operation,  including  a  thoro  shaving  down  of 
the  facial  spur,  thoro  removal  of  the  inner  mastoid  wall  and  also  the 
mastoid  tip,  free  exposure  of  the  posterior  and  middle  skull  fossae.  For 
this  method  of  radical  operation  Neumann  claims  the  advantages,  first, 
of  thoro  inspection  of  the  neighboring  vital  structures  (middle  and  pos- 
terior fossoe)  for  any  pathologic  changes  that  may  have  clinically 
escaped  our  attention ;  second,  of  permitting  the  greatest  possible  roc-u 
for  the  performance  of  the  subsequent  labyrinth  operation ;  third,  of 
more  prompt  healing  after  the  operation,  since  the  dura  of  both  the 
middle  and  posterior  fossa  tends  to  prolapse  somewhat  into  the  wound 
cavity,  thereby  lessening  its  size. 

The  second  part  of  the  operation  consists  in  complete  removal  of  the 
semicircular  canals,  free  opening  of  the  vestibule  and  cochlea.  This 
part  of  the  operation  is  begun  by  removing  the  posterior  wall  of  the 
pyramid  with  the  chisel  from  behind,  the  posterior  vertical  canal  is  re- 
moved and  the  common  orifice  of  the  two  vertical  canals,  then  the  pos- 
terior crus  of  the  horizontal  canal.  The  removal  of  the  posterior  wall 
of  the  pyramid  is  continued  to  the  internal  auditory  canal.  The  danger 
of  opening  the  subdural  space  (as  Jansen  fears)  at  the  entrance  of 
the  ductus  endolymphaticus  is  very  slight  indeed,  sine?  the  saccus  endo- 
lymphaticus  lies  between  two  layers  of  the  dura  (interdural  space)  and 
not  below  the  dura.  The  anterior  crus  of  the  horizontal  canal  is  left  till 
later.  The  bone  in  the  solid  angle  between  the  three  canals  is  attacked 
next  to  gain  an  entrance  into  the  posterior  part  of  the  vestibule,  this  is 
accomplished  by  using  the  smallest  chisels  (Alexander,  number  6  or  7). 
After  opening  the  vestibule  at  this  point  the  opening  is  enlarged  very 
carefully,  often  by  using  the  chisel  as  a  plane,  removing  the  bone  in  thin 


90  PROGNOSIS  AND  TREATMENT. 

layers.  The  lateral  vestibular  wall  is  then  thoroly  removed  and  next 
the  promontory,  permitting  the  freest  possible  opening  of  the  cochlea. 
At  this  stage  a  probe  introduced  into  the  anterior  opening  behind  the 
facial  canal  should  present  itself  thru  the  posterior  opening.  The  bridge 
of  bone  containing  the  facial  canal  is  well  preserved  and  to  aid  in  its 
preservation  as  much  of  the  anterior  crus  of  the  horizontal  canal  as  pos- 
sible is  allowed  to  remain  until  the  final  step.  The  final  step  consists  in 
removing  the  entire  upper  wall  of  the  horizontal  "canal  to  the  ampulla. 
Neumann  usually  includes  in  his  operation  the  removal  of  the  lateral 
wall  of  the  internal  auditory  canal.  He  does  not  fear  to  the  same  extent 
the  dangers  of  injury  to  the  facial  canal,  the  carotid,  the  internal  audi- 
tory canal  and  the  bulbus  jugularis  as  does  Jansen,  and  I  believe,  too, 
that  these  dangers  are  over  estimated  and  are  really  of  less  importance 
than  the  thoro  removal  of  the  diseased  parts. 

COMPARISON    OF    THE    OPERATIONS. 

The  Jansen  "tympanic"  method  has  the  following  disadvantages : 

1.  If,  as  Jansen  himself  cautions  against,  the  dura  is  accidentally 
exposed  or  injured  at  the  time  of  the  operation,  the  injury  is  so  fine  as 
to  be  invisible  and  escapes  our  notice ;  this  makes  the  danger  of  com- 
plications following  vastly  greater  than  where  the  dura  is  well  exposed 
or  a  larger  incision  of  the  dura  has  been  made.    The  dangers  of  small 
invisible  injuries  to  the  dura  have  been  pointed  out  long  since  by 
Koerner  and  Alexander. 

2.  In  the  event  of  slight  or  beginning  intracranial  complications 
(extradural  granulations  or  abscess,   serous  meningitis,   etc.)    which 
may  have  escaped  clinical  diagnosis  we  are  unable  to  inspect  the  parts 
at  the  time  of  operation. 

3.  In  the  event  of  intracranial  complications  following  the  labyrinth 
operation,  they  are  much  more  difficult  to  get  at,  because  of  the  pres- 
ence of  the  extra  bone  and  tissue  we  are  compelled  to  remove,  which 
would  not  exist  had  the  endocranial  method  of  operation  been  originally 
performed. 

4.  When  the  cochlea,  which  is  always    involved    in    acute    diffuse 
labyrinth  suppuration,  is  left  unopened,  as  Jansen  frequently  does,  the 
danger  of  a  meningitis  is  quite  as  great  as  tho  he  had  performed  no 
operation  at  all.    This  undoubtedly  accounts  for  his  exceedingly  high 
post  operative  mortality  (25  per  cent). 

Since  advantages  imply  a  comparison  of  one  with  another,  I  fail  to 


LABYRINTH  PAPERS.  91 

see  any  advantage  of  the  Jansen  operation  over  that  of  the  Neumann 
modified  endocranial  method,  or  even  the  Hinsberg  operation. 

Disadvantages  of  the  Hinsberg  operation  are  much  the  same  as  those 
given  for  the  Jansen ;  they  are  briefly : 

1.  Too  little  room  to  work,  as  in  the  Jansen  tympanic  method.    ' 

2.  The  bone  forceps  of  Bourquet  used  to  enlarge  the  oval  window 
are  apt  to  slip  and  injure  the  facial  behind,  or  by  using  too  much  press- 
ure the  tip  of  the  forceps  may  injure  the  carotid  in  front.    At  best  the 
forceps  are  less  under  our  control,  obscure  our  field  more  and  are  gen- 
erally clumsier  than  either  the  chisel  or  the  burr. 

3.  Since  Hinsberg's  operation  is  a  "tympanic"  method  like  that  of 
Jansen's,  it  is  subject  to  the  same  general  disadvantage  (see  above). 

Hinsberg's  method  has  at  least  one  pronounced  advantage  over  that 
of  Jansen's  in  that  Hinsberg  includes  the  opening  of  both  vestibule  and 
the  cochlea ;  hence  his  much  lower  post  operative  mortality  (4  per  cent, 
in  69  cases — Heine,  Oper.  am  Ohr.,  page  118)  than  Jansen's  (25  per 
cent). 

The  Neumann  method  has  no  disadvantage  compared  with  the  Jan- 
sen or  Hinsberg  methods ;  on  the  other  hand,  it  has  many  advantages — 
fewer  however  over  the  Hinsberg  than  over  the  Jansen  method ;  they 
are: 

1.  The  advantage  of  the  greatest  possible  exposure  of  the  field  of 
operation  to  the  view  of  the  operator,  with  an  opportunity  of  inspecting 
the  dura  of  both  fossae  and  the  sinus. 

2.  The  advantage  of  the  greatest  possible  room  for  the  manipula- 
tion of  instruments  in  the  performance  of  the  operation. 

3.  The  advantage  of  increased  accessibility  to  intracranial  structures 
in  the  event  of  postoperative  complication. 

4.  Quicker  afterhealing  than  after  either  the  Hinsberg  or  Jansen 
operation. 

The  advantages  and  disadvantages  of  the  three  methods  of  operating 
can  be  told  furthermore  mathematically  by  a  comparison  of  the  figures 
of  the  postoperative  mortality.  Out  of  100  cases  Jansen's  postoper- 
ative mortality  is  25  per  cent.  Out  of  70  cases  Hinsberg's  mortality 
about  4  per  cent.  Out  of  the  not  yet  computed  number  of  cases 
operated  since  1906  in  the  Politzer  and  Urbantschitsch  clinic  after  the 
Neumann  method  a  mortality  of  o  per  cent.  One  case,  however,  ended 
fatally  as  a  result  of  an  intercurrent  attack  of  facial  erysipelas  (Barany, 
Phys.  u.  Path,  des  Bog.  Ap.,  1907,  page  49). 


92  PROGNOSIS  AND  TREATMENT. 

It  is  claimed  that  figures  do  not  lie,  nor  do  they ;  but  at  the  same  time 
I  will  not  go  so  far  as  to  say  that  these  differences  in  mortality  were  due 
entirely  to  the  differences  in  the  methods  of  operation  employed  but 
also  to  the  difference  in  the  ability  of  these  men  to  make  the  diagno- 
sis and  select  their  cases  from  the  indications. 

In  closing  the  subject  I  still  insist  that  the  ability  to  operate  is  of 
secondary  importance  to  our  ability  to  diagnose,  and  I  would  trust 
myself  with  labyrinthine  infection  in  the  hands  of  a  diagnostician  be- 
fore I  would  the  operator,  providing  the  one  knew  nothing  of  the  sub- 
ject of  the  other. 

DRESSINGS  AND  AFTER-TREATMENT. 

At  the  completion  of  the  labyrinth  operation  the  wound  cavity  should 
be  thoroly  cleansed  and  washed  out.  In  doing  this  some  operators  use 
hydrogen  dioxide,  others  a  weak  formaldehyde  solution  (l/2  to  i  per 
cent.),  and  still  others  use  both  solutions,  the  hydrogen  dioxid  first  fol- 
lowed by  formalin;  each  of  these  solutions  to  remain  in  the  wound 
cavity  for  a  very  brief  period.  The  danger  of  hydrogen  dioxid  spread- 
ing the  infection  to  neighboring  parts  is  less  feared  today  than  form- 
erly, and  most  surgeons  doubt  its  possibility  altogether.  \Yhether  the 
one  or  the  other  or  both  of  these  solutions  have  been  used,  they  should 
be  followed  by  copious  quantities  of  sterile  water. 

After  thoro  cleansing  of  the  wound  cavity,  as  above  described,  a 
careful  inspection  should  be  made  of  the  neighboring  parts,  especially 
of  the  sinus  and  dura,  for  other  complications. 

Normally  the  sinus  should  present  a  smooth,  somewhat  glistening 
surface,  blue  in  color  and  normally  distended.  The  dura  should  pre- 
sent a  smooth  glistening  surface,  of  a  pearly,  faintly  bluish  white  color; 
it  should  be  very  loosely  adherent  to  the  inner  surface  of  the  bone,  from 
which  it  can  be  readily  separated  by  a  suitable  instrument  (dura  pro- 
ector)  ;  furthermore  there  should  be  neither  bulging  nor  prolapse  of  the 
dura.  Any  deviation  from  the  above  appearances  of  sinus  or  dura 
indicates  some  pathologic  condition. 

Granulations  on  the  sinus  are  recognized  by  the  red  or  brownish 
discoloration  with  unevenness  of  the  surface  and  the  tendency  to  bleed. 
Occasionally  there  may  be  free  pus  found  in  association  with  these 
granulations,  when  the  condition  is  spoken  of  as  a  perisinus  abscess. 
These  granulations,  or  perisinus  abscess,  may  or  may  not  be  associated 
with  sinus  phlebitis  and  thrombosis  but  more  often  they  are  not.  The 


LABYRINTH  PAPERS.  93 

treatment  consists  of  the  thoro  removal,  preferably  by  bone  forceps,  of 
all  overlying  bone  until  normal  sinus  wall  is  reached,  so  that  at  the 
completion  of  our  efforts  the  granulations  or  abscess  should  be  com- 
pletely surrounded  by  a  zone  of  healthy  tissue. 

The  subject  of  sinus  thrombosis  is  so  immense  that  the  writer  will 
not  even  attempt  a  brief  outline  of  the  subject  at  this  time,  but  will 
refer  those  interested  to  the  text  books ;  to  Koerner's  work — "Erkrank 
des  Hirns  der  Hirnhaute  und  cler  Blutleiter" — or  to  a  recent  paper  by 
Alexander,  translated  by  Dr.  Geo.  Davis,  of  New  York  (Archives  of 
Otology,  1908). 

Extradural  granulations  are  recognized  by  the  same  general  appear- 
ances as  when  found  upon  the  sinus  wall.  These  may  also  be  asso- 
ciated with  free  pus,  when  we  recognize  the  condition  as  an  extradural 
abscess. 

In  every  case  of  extradural  abscess  a  careful  inspection  should  be 
made  for  the  purpose  of  determining  the  presence  of  a  communicating 
fistula  leading  to  a  brain  abscess.  Where  no  fistula  is  found  we  should 
treat  the  extradural  granulations  or  abscess  after  the  manner  of  treat- 
ment for  the  same  condition  of  the  sinus  described  above.  If  on  the 
other  hand  the  presence  of  fistula  has  been  determined  it  should  be  en- 
larged and  the  deeper  brain  abscess  opened  and  drained.  For  this 
purpose  the  writer  advises  the  use  of  a  freshly  sterilized,  double  edged,- 
graduated  brain  knife.  Puncture  needles  are  to  be  condemned  as  too 
dangerous  and  unreliable  instruments  to  be  used  in  the  brain  or  sinus. 

Bulging  or  prolapse  of  the  dura  thru  the  openings  which  have  been 
made  in  the  skull  fossa  indicates,  in  a  general  way,  an  increase  of  intra- 
cranial  pressure.  A  moderate  degree  of  circumscribed  bulging  with 
discoloration  of  the  dura  (usually  dark)  indicates  subdural  abscess. 
The  treatment  consists  of  free  opening  of  the  abscess  with  a  freshly 
sterilized  knife.  A  moderate  degree  of  prolapse  of  the  dura  indicates 
more  frequently  a  serous  leptomeningitis  or  meningoencephalitis,  less 
frequently  a  brain  abscess.  The  degree  of  prolapse  in  brain  abscess  is 
variable,  depending  upon  the  size  and  the  stage  of  advancement  of  the 
abscess.  In  all  suspected  cases  of  brain  abscess  free  paracentesis  with 
the  previously  mentioned  brain  knife  should  be  made,  and  it  is  surpris- 
ing how  frequently  our  suspicions  will  be  verified.  In  all  cases  of  pro- 
lapse, even  of  moderate  degree,  the  dura  should  be  freely  incised,  at 
least  one  large  incision  for  the  posterior  and  a  second  one  for  the  middle 
fossa.  In  case  of  serous  meningitis  or  meningoencephalitis  the  brain 


94  PROGNOSIS  A.\D  TREATMENT. 

substance  prolapses  thru  the  dural  incision.  If  the  prolapse  is  very 
marked  and  the  convolutions  flattened  to  any  extent  a  further  puncture 
of  the  lateral  ventricle  of  that  side  is  indicated. 

A  marked  degree  of  prolapse  indicates  suppurative  meningitis.  In 
these  cases  the  symptomatology  will  have  aided  us  considerably  in  our 
diagnosis.  Here  the  same  incision  as  in  the  case  of  serous  meningitis 
is  indicated,  together  with  puncture  of  the  ventricle  and  lumbar  punct- 
ure. When  making  the  dural  incisions  a  milky  or  purulent  fluid 
escapes.  With  suppurative  meningitis  the  prolapse  of  brain  substance 
thru  the  dural  incision  acts  more  or  less  as  a  plug,  interfering  with  the 
drainage  of  pus  from  the  surrounding  areas ;  for  this  reason  some  have 
attempted,  with  more  or  less  success,  the  making  of  counter  openings 
in  the  skull  and  dura  at  distant  points. 

In  suppurative  meningitis  when  not  too  far  advanced  this  operative 
treatment  has  been  fairly  satisfactory  and  more  is  to  be  hoped  for  in 
the  future. 

DRESSINGS. 

The  materials  required  for  the  dressings  are  the  same  whether  the 
operation  for  labyrinth  suppuration  alone  has  been  performed  or 
whether  a  more  complex  operation  to  include  the  treatment  of  some  of 
the  other  complications.  The  only  difference  in  these  cases  is  in 
the  manner  of  applying  the  dressings. 

The  materials  needed  are  (a)  freshly  sterilized  moist  iodoform  gauze, 
prepared  in  narrow  strips  (i  to  il/2  inches  wide)  and  of  convenient 
lengths  for  handling.  As  a  substitute  for  the  iodoform  gauze  some 
operators  have  been  using  iodoform  docht  (the  German  for  wick)  pre- 
pared in  small  bundles  of  ten  or  a  dozen  strands  each,  the  bundles  held 
loosely  correspond  in  size  to  the  thickness  of  an  infant's  finger.  For  the 
wicks  the  advantages  are  claimed  that  they  are  easier  to  introduce,  es- 
pecially into  small  openings,  are  more  readily  removed  and  with  less 
discomfort  to  the  patient  than  iodoform  gauze  since  a  strand  or  two 
may  be  removed  at  a  time  if  so  desired. 

(b)  Additional  strips  of  iodoform  gauze,  about  2  inches  wide  and  of 
considerable  length,  but  folded. 

(c)  Plain  gauze,  folded  into  4  inch  squares,  of  four  or  five  thick- 
nesses. 

(d)  Gauze  bandage. 

(e)  Starch  bandage  or  adhesive  strips. 


LABYRINTH  PAPERS.  95 

In  case  of  labyrinth  suppuration  without  other  complications,  the 
dressings  are  applied  according  to  the  following:  After  ligating  the 
vessels  and  suturing  the  plastic  flap  or  flaps,  we  introduce  the  moist 
freshly  sterilized  iodoform  gauze  or  wick,  first  into  the  very  bottom  of 
the  wound  cavity,  and  then  fill  up  the  cavity  partially.  A  second  piece 
of  the  same  material  is  then  introduced  into  the  cavity  thru  the  external 
meatus ;  this  second  piece  should  be  packed  in  tightly  against  the  plastic 
flap  in  its  new  position.  The  entire  cavity  of  the  wound  is  then  filled 
up  to  the  level  of  the  surface  with  the  remnants  of  the  posterior  piece 
if  the  quantity  is  sufficient,  or  a  third  piece  may  be  used  for  the  pur- 
pose. Most  operators  prefer  a  fairly  tight  packing  for  the  first  dress- 
ing. Over  the  moist  iodoform  gauze  or  wick  a  few  strips  of  the  wider 
iodoform  gauze  is  applied,  and  over  this  the  plain  gauze,  using  8  or  10 
squares.  The  first  4  or  5  plain  gauzes  should  be  unfolded  and  laid  on 
loosely  thus  moulding  the  dressings  better,  they  also  tend  to  stick  or 
adhere  less  when  we  come  to  remove  them.  Over  all  is  applied  a  2 
inch  gauze  bandage  (personally  the  writer  prefers  the  Koerner  method 
of  bandaging),  and  finally  a  starch  bandage  or  adhesive  plaster  is  used 
to  hold  all  in  place. 

It  is  never  advisable  to  sew  up  the  wound,  partially  or  competely, 
after  the  labyrinth  operation  or  where  the  cranial  cavity  has  been 
opened.  Secondary  closure  of  the  retroauricular  opening  may  be  done 
after  a  few  weeks. 

The  only  variation  in  the  dressing  of  those  cases  associated  with 
other  complications  is  in  the  application  of  the  dressings.  In  these 
cases  care  should  be  exercised  to  see  that  the  moist  iodoform  gauze 
or  wick  is  applied  directly  to  the  granulations  or  into  the  openings 
made  in  the  dura  in  cases  of  meningitis  or  into  the  abscess  cavity  in 
cases  of  brain  abscess. 

After  the  operation  the  patient  should  be  put  to  bed  and  kept  there 
until  the  temperature  reaches  normal  and  the  patient  feels  comfortable. 
Internal  medication  will  be  decided  by  the  symptoms  as  they  may  arise. 

The  dressings  need  not  be  touched  for  from  6  to  10  days  if  the  case 
does  satisfactorily.  After  a  few  days  a  rise  of  temperature,  pain  or 
saturation  of  the  dressings  may  call  for  a  change  of  dressing. 

A  rise  of  temperature  may  indicate  some  acute  infectious  fever,  ton- 
silitis,  facial  erysipelas  or  simple  autointoxication  from  constipation  or 
the  extension  of  intracranial  infection. 

Slight  pain  may  indicate  nothing.    More  intense  pain  may  indicate  a 


96  PROGNOSIS  AXD   TREATMENT. 

too  tightly  applied  bandage  or  the  spreading  of  infection;  especially 
meningitis  when  the  pain  is  associated  with  cerebral  vomiting,  choked 
disc,  diminution  in  the  pulse  rate,  etc. 

Early  saturation  of  the  dressings  with  bloody  colored  watery  fluid 
indicates  escape  of  cerebrospinal  fluid. 

All  of  these  conditions  indicate  early  partial  or  complete  redressing 
of  the  wound.  On  the  other  hand,  if  every  thing  goes  along  smoothly 
the  first  redressing  may  be  made  on  or  about  the  sixth  day.  At  this 
time  we  should  remove  all  that  can  be  removed  readily.  In  case  the 
iodoform  gauze  immediately  next  the  wound  surface  adheres  firmly 
it  is  best  not  to  remove  it  but  to  allow  the  adhering  part  to  remain  until 
the  next  redressing.  Providing  the  wound  shows  healthy  granulations 
the  first  redressings  should  be  made  considerably  looser  than  the  pri- 
mary dressing. 

Redressings  should  be  made  every  day  or  two,  according  to  the 
behavior  of  the  wound  and  the  amount  of  secretion.  The  greater  the 
amount  and  the  more  purulent  its  character  the  oftener  the  redressing 
should  be  made. 

In  labyrinth  suppuration  healing  takes  place  about  as  promptly  or 
more  promptly  than  after  one  of  the  radical  operations ;  furthermore, 
after  the  third  or  fourth  redressing  less  care  need  be  exercised  than  in 
the  case  of  the  radical  mastoid  where  the  conservation  of  hearing  De- 
comes  a  factor  in  the  after-treatment. 

After  the  labyrinth  operation  the  rapid  filling  up  of  the  wound  cavity 
with  granulations  resulting  in  obliteration  of  the  middle  ear  spaces  is 
not  contraindicated  as  in  other  cases  of  ordinary  chronic  middle  ear 
suppuration. 

The  secondary  sutures  for  closure  of  the  retroauricular  opening  may 
be  performed  after  two  or  three  weeks  or  when  all  acute  symptoms 
have  disappeared.  Final  healing  takes  place  in  from  two  to  three 
months,  when  the  patient  may  be  discharged. 


PHYSIOLOGY  AND  PATHOLOGY  OF  THE  NON-ACOUSTIC 
OR,  SO-CALLED,  STATIC  LABYRINTH 

THE  ANATOMY. 

FOR  the  thorough  understanding  of  the  physiology  of  any  part 
of  the  body  one  must  have  at  least  a  fair  knowledge  of  the 
anatomy  (gross  and  microscopic)  of  that  part,  together  with 
some  knowledge  of  its  relation  to  other  parts.  These  facts  are  es- 
pecially true  with  regard  to  the  labyrinth,  and  for  this  reason  the  author 
will  devote  the  entire  first  paper  to  this  part  of  the  subject.  It  is  not 
intended  that  this  paper  should  be  a  complete  work  upon  the  anatomy 
of  the  ear ;  on  the  contrary,  only  as  much  of  the  anatomy  will  be  con- 
sidered as  is  absolutely  necessary  for  the  understanding  of  the  physi- 
ology and  pathology  and  the  reactions  of  the  labyrinth  under  normal 
and  pathologic  conditions  to  be  described  in  subsequent  papers. 

OSSEOUS  LABYRINTH  OR  LABYRINTH  CAPSULE. 

The  osseous  labyrinth  is  formed  of  compact,  densely  lamellated  bone, 
quite  complex  in  shape  as  its  name  would  indicate  and  located  within 
the  pyramid  of  the  temporal  bone.  It  is  surrounded,  with  the  exception 
of  parts  of  its  lateral  surface,  with  diploetic  or  pneumatic  bone.  When 
of  pneumatic  bone,  the  cells  form  part  of  the  mastoid  cells,  are  lined 
with  mucous  membrane  and  are  in  direct  communication  with  the  mas- 
toid antrum. 

The  character  of  the  bone  surrounding  the  osseous  labyrinth  is  im- 
portant, less  from  the  physiologic  than  from  the  pathologic  standpoint. 
The  danger  of  labyrinth  sequestration  from  an  attack  of  mastoiditis  is 
increased  directly  in  proportion  to  the  pneumatic  and  inversely  to  the 
diploetic  character  of  the  surrounding  perilabyrinthine  bone. 

The  osseous  labyrinth  is  composed  of  three  essential  parts  :  ( I )  The 
cochlea;  (2)  The  vestibule;  (3)  The  three  Semicircular  Canals. 

The  osseous  cochlea  is  a  hollow  tube,  wound  2.^/2  times  about  a 
conical  shaped  axis  called  the  modiolus.  The  largest  diameter  of  the 
tube  is  at  the  base  and  it  tapers  gradually  toward  and  terminates  in  a 
blind  end  on  the  summit  of  the  modiolus,  known  as  the  cupula  cochleae. 
The  cochlear  tube  is  partly  divided  into  two  parts  by  a  spiral  shaped 
7 


98  \0.\'-.-lCOL'STIC  OR  STATIC  LABYRINTH. 

process  of  bone,  called  the  lamina  spiralis  ossea,  which  projects  from  the 
modiolus  and  runs  its  entire  length,  terminating  in  a  sickel  shaped  lip  at 
the  apex,  called  the  hnmulus.  The  lamina  spiralis  ossea  incompletely 
separates  the  cochlea  into  a  lower  semicircular  shaped  tube,  known  as 
scala  tympani,  and  an  upper  one,  known  as  the  scala  vestibuli.  The 
separation  of  the  two  scalar  is  completed  by  the  lamina  spiralis  mem- 
branacea  (of  the  membranous  labyrinth)  excepting  at  the  apex  where 
the  two  scalae  communicate  around  the  tip  of  the  hamulus ;  this  space 
of  communication  is  known  as  the  helicotrema.  The  scala  vestibuli 
opens  at  the  lower  end  into  the  cavity  of  the  vestibule.  The  scala 
tympani  ends  somewhat  beyond  the  fenestra  rotunda.  The  fenestra 
rotunda  is  closed  by  the  membrana  secunda. 

The  modiolus  is  composed  of  spongeous  bone  and  contains  a  fairly 
large  spiral  shaped  canal  which  also  terminates  in  a  blind  end  at  the 
apex.  This  canal  accommodates  the  ganglion  spirale  cochleae.  Another 
smaller  spiral  shaped  canal  within  the  modiolus  accommodates  the 
artery,  ramus  cochleae  a  branch  from  the  arteria  auditive  intense,  and 
its  subdivisions.  The  accompanying  veins  run  in  a  separate  canal. 
The  base  of  the  modiolus  presents  inwardly  at  a  slight  angle  to  the 
internal  auditory  foramen.  f 

In  the  scala  tympani  of  the  lowest  whorl  of  the  osseous  cochlea  just 
anterior  to  the  fenestra  cochlea  is  a  small  opening,  the  apertura  interna 
canaliculi  cochleae,  for  the  transmission  of  the  perilymphatic  duct 
(ductus  perilymphaticus). 

The  osseous  cochlea  contains  the  pars  inferior  labyrinthi,  which  com- 
prises the  hearing  organ.  u 

The  vestibulum  is  that  part  of  the  osseous  labyrinth  which  is  more 
or  less  sack  shaped,  lying  between  the  cochlea  anteriorly  and  the  semi- 
circular canals  posteriorly,  taking  up  much  less  space  than  either. 
On  its  upper  and  outer  surface  are  two  rounded  prominences  which  lie 
just  next  to  each  other  with  a  wedge  shaped  depression  or  incision  be- 
tween them ;  the  anterior  prominence  is  known  as  the  recessus  spheri- 
cus, a  better  name  would  be  prominentia  sphericus ;  the  posterior  is 
known  as  the  recessus  ellipticus.  The  depression  between  the  two 
prominences  is  known  as  the  crista  vestibuli.  As  the  names  imply,  the 
recessi  and  crista  are  strictly  speaking  correct  only  when  viewed  from 
the  inner  aspect.  The  recessus  sphericus  accommodates  the  sacculus 
and  the  recessus  ellipticus  the  utriculus  of  the  membranous  labyrinth, 


LABYRIXTH  PAPERS.  >» 

and  the  depression  on  the  outer  surface  corresponds  with  the  crista  be- 
tween these  two  recesses. 

On  the  external  surface  of  the  vestibule,  a  short  distance  below  the 
two  prominences  above  mentioned,  is  a  kidney  shaped  window,  the 
fenestra  vestibuli,  the  long  axis  of  which  is  somewhat  oblique  from 
above  and  forward  to  below  and  backward ;  the  concavity  corresponds 
to  the  hilus  of  the  kidney,  is  downward  and  forward.  This  window  is 
closed  by  the  stapes  plate  (basis  stapedis).  There  is  no  anterior  sur- 
face of  the  vestibule  but  that  part  corresponding  to  it  opens  into  the 
lower  cochlear  whorl,  so  that  the  vestibule  appears  somewhat  as  a  mo-e 
or  less  rounded  body  resting  upon  but  too  large  to  fit  into  a  cornucopia. 

The  anterior  inferior  part  of  the  vestibule  is  represented  by  that  part 
of  the  lowest  cochlear  whorl  which  is  covered  by  the  secondary  mem- 
brane and  slightly  overlaps  the  floor  of  the  vestibule ;  the  part  just  pos- 
terior to  this  represents  the  floor  of  the  vesubule. 

Posteriorly  the  semicircular  canals  open  into  the  vestibule  through 
five  openings ;  the  three  ampullar  ends  of  the  three  canals,  one  separate 
smooth  end  for  the  external  and  one  common  smooth  end  for  the 
two  vertical  canals. 

From  the  median  or  inner  side  the  prominences  representing  the 
recessus  sphericus  and  ellipticus  can  be  seen  above,  the  common  crus  of 
the  two  vertical  canals  posteriorly,  the  ampullar  end  of  the  inferior 
semicircular  canal  inferiorly  and  a  very  narrow  space  in  the  center  of 
all  three  in  which  a  foramen — the  apertura  externa  aqueductus  vesti- 
buli— is  located  which  allows  for  the  transmission  of  the  ductus  endo- 
lymphaticus. 

The  semicircular  canals  are  three  in  number:  (a)  the  External,  Hori- 
zontal or  Lateral;  (b)  the  Superior  or  superior  vertical;  (c)  the  Pos- 
terior, Inferior,  Inferior  Vertical.  These  canals  are  more  or  less  cylind- 
rical shaped  tubes  bent  in  the  form  of  semicircles  or  a  trifle  more  than 
a  semicircle,  they  are  of  almost  uniform  transverse  dimensions,  except- 
ing at  one  end  where  each  canal  terminates  in  a  somewhat  spherical 
shaped  swelling  called  the  ampulla.  Each  canal  therefore  has  two 
ends,  the  ampullar  and  the  nonampullar  or  smooth  end.  The  ampullae 
of  the  three  canals  all  open  directly  into  the  vestibule.  The  smooth 
end,  crus  simplex  of  the  horizontal  canal  does  likewise,  but  the  smooth 
ends  of  the  two  vertical  canals  open  into  a  common  tube,  the  crus 
commune,  and  it  in  turn  into  the  vestibule. 


ioo  NON-ACOUSTIC  OR  STATIC  LABYRINTH. 

The  locations  of  the  ampullae  are  more  or  less  important.  The  am- 
pulla of  the  horizontal  canal  is  located  at  the  anterior  end  of  the  crus 
ampullare  just  behind  the  facial  canal,  which  separates  it  from  the 
oval  window  on  the  lateral  aspect  of  the  vestibule ;  the  ampulla  of  the 
superior  canal  is  immediately  above  the  ampulla  of  the  horizontal  semi- 
circular canal  on  the  upper  posterior  aspect  of  the  lateral  wall  of  the 
vestibule.  The  ampulla  of  the  inferior  semicircular  canal  is  located 
just  posteriorly  and  medianward  to  the  inferior  wall  of  the  vestibule. 

The  nonampullar  or  smooth  end  of  the  horizontal  semicircular  canal 
opens  into  the  vestibule  at  its  posterior  part. 

The  common  orifice  of  the  vertical  canals  opens  into  the  vestibule  at 
its  posterior  median  part 

The  description  of  the  facial  canal  and  its  course  will  not  be  given 
in  this  paper  since  it  does  not  belong  strictly  to  the  subject. 

That  part  of  the  osseous  labyrinth  which  is  exposed  laterally  forms 
the  greater  part  of  the  inner  wall  of  the  middle  ear,  and  is  recognized 
from  the  tympanic  side  as  the  prominence  of  the  horizontal  semicir- 
cular canal  (prominentia  canalis  semicircularis  lateralis),  part  of  the 
lateral  vestibular  wall  and  the  promontorium  corresponding  to  the 
superior,  posterior  and  lateral  part  of  the  cochlea. 

This  exposure  of  the  lateral  wall  of  the  labyrinth  is  of  clinical  im- 
portance in  the  making  of  the  caloric  test,  as  we  shall  learn  later,  and 
of  pathologic  importance  since  it  offers  especially  vulnerable  points 
for  the  infection  of  the  labyrinth  from  middle  ear  suppuration. 

In  addition  to  the  exposed  parts  just  mentioned,  we  have  two  win- 
dows of  the  labyrinth  exposed  laterally,  the  fenestra  vestibuli  or 
ovalis  and  fenestra  cochleae  or  rotunda,  which  normally  are  sealed  up, 
the  former  with  the  basis  stapedis,  the  latter  with  the  membrana 
secunda.  These  closed  windows  are  of  physiologic  importance  to  the 
function  of  hearing,  but  under  the  destructive  influence  of  middle  ear 
suppuration  they  may  become  open  gates  for  the  spread  of  infection 
to  the  labyrinth. 

The  basis  stapedis  separates  the  tympanic  cavity  on  the  external  side 
from  the  perilymphatic  space  in  the  vestibule  on  the  median  side.  The 
membrana  secunda  separates  the  tympanic  cavity  on  the  external  side 
from  the  perilymphatic  space  at  the  bottom  of  the  scala  tympani  on  the 
median  side. 

The  fenestra  vestibuli  and  the  fenestra  cochleae  are  both  located  at 


Figure  i. — A  mould  of  the  right  osseous  labyrinth   (lateral  view)    after   Spalt- 

eholz. 

I — Canalis  semicircularis  superior.  2 — Ampulla  ossea  superior.  3 — Recessus 
ellipticus.  4 — Recessus  sphericus.  5 — Cupula  cochleae.  6 — Middle  cochlear 
whorl.  7 — Upper  cochlear  whorl.  8 — Lower  cochlear  whorl.  9 — Location  of 
crista  vestibuli.  10 — Fenestra  cochleae,  n — Fenestra  vestibuli.  12 — Ampulla 
ossea  posterior.  13 — Canalis  semicircularis  posterior.  14 — Crus  simplex.  15 — 
Crus  ampullare.  16 — Ampulla  ossea  lateralis.  17 — Crus  commune. 


Figure  2. — Median  wall  of  the  right  tympanic  cavity  of  the  adult  human — after 
Spalteholz  (enlarged  5  diameters). 

I — Boundary  between  antrum  tympanicum  and  recessus  epitympanicus.  2 — 
Tegmen  tympani.  3 — Paries  tegmentalis.  4 — Prominentia  canalis  facialis.  5 — 
Tendo  M.  stapedii.  6 — Plica  stapedis.  7 — Processus  cochleariformis.  8 — M.  ten- 
sor tympani.  9 — Stapes.  10 — Paries  labyrinthicus.  n — Septum  canalis  mus- 
culotubarii.  12 — Ostium  tympanicum  tubae.  13 — Pars  ossea  tubse.  14 — Paries 
carotious.  15 — Plexus  tympanicus  (Jacobsoni)  im  sulcus  promontorii.  16 — Cell- 
ulae  tympanicae.  17 — Paries  jugularis.  18 — Promontorium.  19 — Fossula  fenestrae 
cochleae.  20 — Subiculum  promontorii.  21 — Paries  mastoideus.  22 — Sinus 
tympani.  23 — Eminentia  pyramidalis.  24 — Sinus  posterior.  25 — Fossa  incudis. 
26 — Prominentia  canalis  semicircularis  lateralis.  27 — Recessus  epitympanicus. 
28 — Antrum  tympanicum. 


LABYRINTH  PAPERS. 


103 


the  bottom  of  bony  niches  (see  Fig.  II).  These  niches  serve  normally 
as  a  protection  against  direct  injury ;  on  the  other  hand,  during  an  at- 
tack of  middle  ear  suppuration  they  serve  as  reservoirs  for  the  reten- 
tion of  pus  and  as  beds  for  granulations.  Thus  these  niches  while 


Figure   3. — The   right   temporal   bone   viewed    from   the   posterior   median    and 

slightly  inferior  aspect. 

I — Meatus  acusticus  internus.  2 — Superior  petrosal  groove.  3 — Aqueductus 
cochleae.  4 — Aqueductus  vestibuli.  5 — Groove  for  the  lateral  sinus.  6 — Pro- 
cessus  styloideus.  7 — Inner  surface  of  the  squamous  portion. 

diminishing  the  vulnerability  of  the  labyrinth  to  traumatism  increase 
it  to  infection. 

The  labyrinth  capsule  is  perforated  cranialwards  by  its  three  fora- 
minae,  two  of  which  are  represented  on  the  posterior  median  surface  of 
the  temporal  bone  by  the  meatus  acusticus  internus  and  the  aqueductus 
vestibuli;  and  the  third,  aqueductus  cochleae,  is  directly  below  the 
meatus  acusticus  internus. 


104 


NOX-ACOUSTIC  OR  STATIC  LABYRINTH. 


The  meatus  acusticus  interims  perforates  the  posterior  median  sur- 
face of  the  petrous  bone  at  about  one-third  the  distance  from  the  tip 
in  an  oblique  direction  outward  and  slightly  backward,  so  that  the  angle 


Figure  4. — Fimdus  meatus  auditor!!   intern!  of  the  right  temporal  bone  of  a 

child — after  Schwalbe. 

I — Crista  falciformis.  2 — Spiral  crista  corresponding  to  the  spiral  turnings  of 
the  cochlea  and  defining  the  tractus  spiralis  foraminulentus.  3 — Canalis  N. 
facialis — opening  for  nervus  facialis.  4 — Area  cribrosa  superior  for  the  passage  of 
the  branches  of  vestibular  nerve  which  go  to  the  macula  sacculi.  5 — Area  cribrosa 
media  for  the  passage  of  branches  of  vestibular  nerve  which  go  to  macula  utri- 
culi.  6 — Foramen  singulare  for  the  N.  ampullaris  posterior.  7 — Tractus  spiralis 
foraminulentus  for  the  passage  of  the  branches  of  the  ramus  cochlea.  8 — Fora- 
men centrale  cochleae. 

between  the  canal  and  the  surface  of  the  bone  directly  posterior  to  the 
canal  is  quite  acute  (25°).  At  the  depth  of  about  6  mm.  from  the 
posterior  lip  of  the  meatus  in  a  plane  almost  at  right  angles  to  the  di 


LABYRINTH  PAPERS.  105 

rection  of  the  canal  or,  in  other  words,  in  the  sagittal  plane,  the  canal 
is  partially  obstructed  by  a  perforated  plate  of  bone.  Through  the 
perforations  pass  the  VII  (Facial)  and  the  branches  of  the  VIII 
(Acoustic)  nerves.  These  perforations  are  illustrated  in  Fig.  IV. 

The  aqueductus  vestibuli  viewed  from  below  is  a  slit-like  foramen 
on  the  posterior  median  surface  of  the  petrous  bone,  about  il/2  cm. 
external  to  and  slightly  below  the  level  of  the  meatus.  Immediately 
below  it  is  a  small,  more  or  less  rounded,  depression  for  the  accom- 
modation of  the  saccus  endolymphaticus. 

The  aqueductus  cochleae  is  another  slit-like  foramen  on  the  lower 
edge  of  the  posterior  median  surface  of  the  pyramid,  immediately  be- 
low the  meatus  acusticus  internus ;  it  serves  for  the  exit  of  the  ductus 
perilymphaticus  from  the  scala  tympani  of  the  lower  cochlear  whorl 
previously  mentioned. 

MEMBRANOUS  LABYRINTH. 

The  membranous  labyrinth  takes  more  or  less  the  form  of  the  os- 
seous labyrinth  with  the  exception  of  two  sacs,  the  sacculus  and  utri- 
culus,  located  within  the  cavity  of  the  vestibulum  (see  Figs.  V,  VI  and 
VII). 

The  membranous  labyrinth  is  composed  of  four  essential  parts:  (i) 
The  Ductus  Cochlearis,  a  membranous  tube  within  the  osseous  cochlea, 
taking  the  same  spiral  turns  and  ending  in  a  blind  end  at  the  apex 
(csecum  cupulare)  ;  (2)  The  Sacculus,  a  more  or  less  pear  shaped  sac 
resting  in  the  recessus  sphericus  of  the  vestibule;  (3)  The  Utriculus, 
an  irregularly  ovoid  shaped  sac  resting  in  the  recessus  ellipticus  of  the 
vestibule  :  (4)  The  three  Semicircular  Canals,  corresponding  and  loose- 
ly adherent  to  the  osseous  canals.  At  one  end  of  each  of  these  semi- 
circular canals  as  they  enter  the  utriculus,  is  a  dilatation  known  as  the 
ampulla. 

The  membranous  is  much  smaller  than  the  osseous  labyrinth ;  it  con- 
tains a  fluid  known  as  the  endolymph.  Surrounding  the  membranous 
labyrinth  is  the  perilymphatic  space  containing  the  perilymph. 

The  ductus  cochlearis  has  two  blind  ends,  the  upper — caec.jm 
cupulare,  already  mentioned — and  a  lower  one  projecting  into  the 
cavity  of  the  vestibule  and  known  as  the  cjecum  vestibulare  (see  Figs. 
VI  and  VII).  Very  close  to  the  latter  is  a  small  duct  (ductus 
reuniens)  leading  from  the  ductus  cochlearis  to  the  sacculus.  More 
about  the  ductus  cochlearis  need  not  be  said  in  this  paper  since  it  does 


io6  \OX-ACOUSTIC  OR  STATIC  LABYRINTH. 

not  bear  upon  the  subject  of  the  physiology  and  pathology  of  the  non- 
acoustic  labyrinth. 

The  sacculus  is  a  sac  somewhat  smaller  in  size  than  the  utriculus  and 
communicates  with  the  ductus  cochlearis  through  the  ductus  reuniens 
and  indirectly  with  the  utriculus  through  the  ductus  utriculosaccularis, 
which  empties  into  the  ductus  endolymphaticus  a  short  distance  after 
the  ductus  endolymphaticus  leaves  the  sacculus.  Surrounding  the 
sacculus  is  the  perilymphatic  space  of  the  vestibule  containing  the  peri- 
lymph. 

The  sacculus  contains  an  important  end  organ  for  the  perception  of 
the  static  function,  known  as  the  macula  acustica  sacculi,  which  re- 
ceives its  nerve  supply  from  the  nervus  saccularis,  a  branch  of  the 
nervus  vestibuli. 

The  utriculus  is  located  somewhat  posterior  and  superior  to  the 
sacculus.  It  has  six  openings,  one  for  the  short  ductus  utriculo-sac- 
cularis,  which  empties  into  the  ductus  endolymphaticus,  and  five  for 
the  three  semicircular  canals;  three  of  these  receive  the  ampullar  ends 
of  the  three  canals,  one  the  nonampullar  end  of  the  external  semicir- 
cular canal,  and  one  the  crus  commune,  which  represents  the  blending 
into  one  of  the  two  smooth  ends  of  the  vertical  canals. 

The  utriculus,  like  the  sacculus,  contains  an  end  organ  for  the  percep- 
tion of  the  static  function,  known  as  the  macula  acustica  utriculi  and 
receives  a  corresponding  branch  (nervus  utriculi)  from  the  vestibular 
nerve. 

The  three  membranous  canals  are  much  smaller,  but  correspond  in 
form  to  the  osseous  canals;  they  are:  (a)  the  ductus  semicircularis 
lateralis,  (b)  superior,  and  (c)  posterior. 

The  spindle  shaped  ampullae  of  the  three  canals  are  known  respect- 
ively as  the  ampulla  membranacea  lateralis,  superior  and  posterior. 
Each  ampulla  contains  an  end  organ  for  the  perception  of  motion  ac- 
celeration in  curved  lines;  of  this  we  shall  speak  further  when  we 
come  to  the  physiology.  These  three  end  organs  are  located  on  a  sort 
of  spine  running  transversely  to  the  canal  within  the  ampulla  on  the 
more  distant  side  (see  Fig.  IX). 

The  membranous  canals  contain  endolymph  which  is  capable  of  mo- 
tion in  two  directions — from  the  canal  to  the  utriculus,  and  vice  versa. 
Surrounding  the  membranous  canal  is  a  space  containing  deli- 
cate fibrous  threads,  which  hold  the  membranous  canal  more  or  less 
fixed  to  the  more  distant  side  of  the  osseous  canals.  This  space  is 
known  as  the  spatium  perilymphaticus  and  contain?  the  perilymph. 


Figure  5. — Right  membranous  labyrinth  of  an  adult  partly  laid  free   (from  the 
lateral  side)  enlarged  5  diameters — after  Spalteholz. 

I — N.  ampullaris  superior.  2 — N.  ampullaris  lateralis.  3 — N.  utricularis.  4 — 
Scala  vestibuli.  5 — Caecum  cupulare.  6 — Helicotrema.  / — Hamulus  ossis  lac- 
rimalis.  8 — Ductus  cochlearis.  9 — Macula  acustica  sacculi  with  N.  saccularis. 
10 — Ductus  reuniens.  n — Canalis  caroticus.  12 — Ductus  cochlearis.  13 — Cut 
surface  of  the  bone.  14 — Ductus  semicircularis  posterior.  15 — Ampulla  mem- 
branacea  posterior.  16 — Caecum  vestibulare.  17 — Sacculus.  18 — 'Utriculus.  19 — 
Macula  acustica  utriculi.  20 — Ampulla  membranacea  lateralis.  21 — Ductus  semi- 
circularis lateralis.  22 — Ampulla  membranacea  superior.  23 — Ductus  semicir- 
cularis superior.  24 — Canalis  semicircularis  superior. 


Figure  6. — Right  membranous  labyrinth  of  an  adult  laid  bare,  viewed  from  the 
median  and  posterior  side,  enlarged  5  diameters — after  Spalteholz 

I — Utriculus.  2 — N.  ampullaris  superior.  3 — Ampulla  membranacea  superior. 
4 — Ductus  semicircularis  superior.  5 — Ampulla  membranacea  lateralis.  6 — 
Ductus  semicircularis  lateralis.  7 — Crus  commune.  8 — Ductus  semicircularis 
posterior.  9 — Ductus  reunien,s.  10 — Ampulla  membranacea  posterior.  II — Sac- 
culus.  12 — N.  ampullaris  posterior.  13 — N.  saccularis.  14 — Ganglion  vesti- 
bulare.  15 — N.  vestibularis.  16 — N.  acusticus.  17 — N.  cochlearis.  18 — Ductus 
cochlearis.  19 — Superior  branch  of  the  vestibularis. 


LABYRINTH  PAPERS. 


109 


MICROSCOPIC  ANATOMY. 

In  considering  the  microscopic  anatomy  of  the  nonacoustic  labyrinth, 
the  cochlea  and  its  membranous  contents  are  naturally  excluded. 

The  nonacoustic  labyrinth  contains  two  types  of  nerve  endings:  (a) 
two  of  the  one  type  located  in  the  sacculus  and  utriculus  are  known  as 
the  macula  acustica  sacculi  and  the  macula  acustica  utriculi ;  (b)  three 


l-'igure  7. — Schematic  representation  of  the  osseous  and  membranous  labyrinths, 
enlarged  5  diameters — after  Spalteholz. 

I — Ductus  atriculosaccularis.  2 — Ampulla  membranacea  superior.  3 — Ductus 
endolymphaticus.  4 — Saccus  endolymphaticus.  5 — Dura  mater  encephali.  6 — Bone. 
7 — Caecum  cupulare.  8 — Helicotrema.  9 — Ductus  cochlearis.  10 — Scala  vestibuli. 
ii — Scala  tympani.  12 — Sacculus.  13 — Ductus  reuniens.  14 — Spatium  perilymph- 
aticum  of  the  vestibule.  15 — Ductus  perilymphaticus.  16 — Fenestra  cochleae.  17 — 
Cavum  tympani.  18 — Caecum  vestibulare.  19 — Fenestra  vestibuli.  20 — Ampulla 
membranacea  posterior.  21 — Canalis  semicircularis  posterior.  22 — Ductus  semi- 
circularis posterior.  23 — Utriculus.  24 — Canalis  semicircularis  superior.  25 — 
Ductus  semicircularis  superior. 

of  another  type  located  in  the  three  ampullae  membranaceae  which  are 
known  as  the  cristae  ampullari. 

It  is  these  two  maculae  and  three  cristae  which  particularly  interest 
us,  and  for  this  reason  we  shall  describe  their  microscopic  anatomy 


no 


XOX-.ICOL'STIC  OR  STATIC  LABYRINTH. 


somewhat  in  detail.    A  description  of  one  macula  will  answer  for  both, 
as  will  also  a  description  of  one  crista  answer  for  the  remaining  two. 

The  macula  acustica  utriculi  is  located  w'thin  the  cavity  of  the 
utriculus.  According  to  Retzius  (das  Gehororgan  der  VVirbeltiere,  II., 
p.  333)  the  long  axis  is  from  above,  in  front  and  inward,  to  behind, 
below  and  outward,  and  the  shorter  diameter  at  right  angles  to 
this  and  somewhat  horizontal.  The  long  axis  of  the  macula  acustica 
sacculi,  according  to  the  same  author,  lies  on  the  median  wall  and  is  al- 


Figure  8. — Cut   through   the   macula   acustica   recessus   utriculi   of  the   human, 
magnified  130  diameter — after  Schwalbe. 

i — Neuro-epithelium  of  the  macula  acustica ;  a,  nuclear  zone ;  b,  zone  free  of 
nuclei ;  upon  the  surface,  ciliae.  2 — Cuboid  cells  at  the  border  of  the  macula.  3 — 
Perilymphatic  net  work  of  connective  tissue  trabeculse.  4 — The  same  but  more 
compact.  5 — The  basement  membrane.  6 — Nerve  bundles  cut  transversely. 

most  vertical,  or  more  exactly  from  above  and  inward  to  below  and 
outward,  and  its  shorter  diameter  is  at  right  angles  to  this  direction. 

The  maculae  receive  the  terminal  nerve  filaments  of  the  nervi  utriculi 
and  sacculi,  branches  of  the  vestibular  nerve.  Each  macula  is  com- 
posed of  a  layer  of  two  distinct  kind  of  cells — (a)  neuro-epithelial 
cells;  (b)  supporting  cells.  The  neuro-epithelial  cells  are  the  actual 
perceiving  cells  (special  sense  cells)  and  contain  short  hairs  or  cilia  of 
uniform  length  extending  into  the  cavity  of  the  sacculus  and  utriculus. 
The  supporting  cells  are  the  alternate  ones  between  the  perceiving  cells  ; 
they  contain  no  cilia  and  have  no  known  function  but  are  supposed  to 
support,  and  the  writer  would  add  to  insulate,  the  perceiving  cells. 


LABYRINTH  PAPERS. 


in 


On  the  surface  of  the  cells  or  the  cilia  of  the  cell  rest  somewhat 
loosely  the  socalled  otoliths,  small  crystalline  bodies  which  are  held 
more  or  less  together  and  to  the  surface  by  a  mucilaginous  substance 
which  prevents  them  from  becoming  separated  or  detached  from  the 
surface  through  change  of  position  of  the  head,  when  for  instance  the 
surface  of  the  macula  is  above  and  the  otoliths  below.  The  macula 
and  otoliths  are  nothing  more  than  a  more  complex  and  higher  de- 
veloped aural  vesical  or  otocyst  with  the  otoliths  found  in  the  craw  fishes 


Figure  9. — Longitudinal  cut  through  the  ampulla — after  Hensen  (schematic). 
I — Semicircular  canal  communication.  2 — Utriculus  communication.  3 — The 
epithelia  of  the  ampullar  roof.  4 — Neuro-epithelia  of  the  crista  ampuliaris  or 
acustica.  5 — The  long  cilia  of  the  neuro-epithelia.  6 — N.  ampuliaris.  7 — Con- 
nective tissue  of  the  crista. 

which  Kreicll  has  demonstrated  to  be  the  static  organ  by  the  iron  filings 
and  magnet  experiment. 

Crista  ampuliaris.  There  are  three  cristae;  one  for  each  mem- 
branous ampulla.  They  are  located  on  the  far  side  of  the  ampullae  on 
the  summit  of  the  prominences  which  project  into  and  narrow  the 
lumen  of  the  ampullae.  These  prominences  are  really  ridges  which  ap- 
pear triangular-shaped  when  viewed  from  the  side  and  more  or  less 
crescent  shaped  when  viewed  lengthwise  of  the  canal ;  in  other  words, 


Figure  10. — Transverse  cut  through  the  medula  oblongata  showing  the  origin 
of  the  nervus  acusticus,  the  Deiter's  and  the  triangular  nuclei.  (From  the 
Mikroskopisch-topographischer  Atlas  des  menschlichen  Zentralnervensystems — 
after  Marburg.) 

Stra  Striae  acusticae.  VIII  av  Pars  vestibularis  radicis  spinalis  acustici. 
Nmv  Nucleus  vestibularis  magnocellularis.  Tnc  Tractus  nucleo-cerebellaris. 
TVIII  Tuberculum  acusticum.  VIIIc  Ramus  cochlearis  asustici.  NVIIIac 
Nucleus  acustici  acessorius.  VIII  Nervus  acusticus.  Crst  Corpus 
restiforme.  Flp  Fasciculus  longitudinalis  dorsalis.  RG  Area  glossopharyngei. 
NIX  Nucleus  glossopharyngei  dorsalis.  m  Fasciculus  longitudinalis  dorsalis. 
Nft  Nucleus  eminentiae  teretis.  Np  XII  Nucleus  praepositus  hypoglossi.  pt 
Fibrae  pretrigeminales.  Trs  Tractus  rubrospinalis.  Tst  Tractus  spinotectalis  et 
thalamicus.  Tscv  Tractus  spinocerebellaris  ventralis.  cH  Fasciculus  tegmeti 
Centralis.  NarcP  Nucleus  arcuatus  pyramidum.  Py  Pyramis.  faev  Fibrae 
arcuatae  externas  ventrales.  Na  Nucleus  ambiguus.  F  c  V  Fasciculi  comitantes 
trigemini.  IX  Nervus  glossopharyngeus.  Va  Radix  spinalis  trigemini.  Sgl 
Substantia  gelatinosa  trigemini.  fai  Fibrae  arcuatae  interns.  Fco  Fibrae  cere- 
bello  olivares.  No  Nucleus  olivaris  inferior.  Oae  Paroliva  dorsalis.  Lm  Lem- 
niscus  dorsalis.  Sra  Substantia  reticularis  alba.  Sri  Substantia  reticularis 
lateralis.  Nci  Nucleus  centralis  inferior.  Ra  Raphe.  Fprd  Fasciculi  predorsalis. 
rt  Fibrae  retrotrigeminales.  it  Fibrae  arciformes  intertrigeminales. 


Fig.  ir.  Longitudinal  cut  through  the  medulla  oblongata  corpora  quadrigemina  and  thala- 
mus  opticus,  showing  Deiter's  Nucleus,  the  eye  muscle,  nuclei  and  the  posterior  longitudinal 
bundle.  (From  the  Mikroskopisch-topographischer  Atlas  des  menschlichen  Zentralnerven- 
systems — after  Marburg) . 

E  W  Nucleus  paryicellularis  oculomotorii.  Nllhn  Nucleus  oculomotorii  medialis.  Nllll 
Nucleus  oculomotorii  lateralis.  VIIIv  Ramus  vestibularis  acustici.  T  Vlll  Tuberculum 
acusticum.  Nvt  Nucleus  abducens.  Flp  Fasciculus  longitudinalis  dorsalis.  Vlll  e  Ramus 
cochlearis  acustici.  Vlll  a  Radix  spinalis  acustici.  Ci  Capsula  interna.  Nc  Nucleus 
caudatus.  St.  "Stria  cornea.  Ndm  Nucleus  dorsalis  magnus  thalami.  Tt  Taenia  thalami. 
Pu  Putamen.  Nl  Nucleus  lateralis  thalami.  Nm  Nucleus  medialis  thalami.  Narc  Nucleus 
arcuatus  thalami.  Nl  Corpus  Luyisii.  Cgm  Corpus  geniculatum  mediale.  Cgl  Corpus  geni- 
culatum  laterale.  IM  Meditullium  lateralle.  Vlll  Ventriculus  tertius.  Lmm  Lamina  medul- 
laris  lateralis.  frtf  Fasciculus  retroflexus.  Ntg  Nucleus  riber  tegmenti.  H.  Fasciculus 
triangularis  Helweg.  Nlve  Nucleus  lateralis  externus  thalami.  Brqp  Brachium  corporis 
quadrigemini  posterioris.  Ncop  Nucleus  commissurae  posterioris.  Ndr.  Nucleus  dorsalis 
raphes.  Brcj  Brachium  conjunctivum.  LI  Lemniscus  lateralis.  NL1  Nucleus  lemnisci 
lateralis.  dl  H  Fasciculus  tegmenti  dorsolateralis.  Lm  Lemniscus  medialis.  N  Vm  Nucleus 
motorius  trigemini.  V  Nervtts  trigemini.  N  Vs  Nucleus  sensibilis  trigemini.  Va  Radix 
spinalis  trigemini.  Crst  Corpus  restiforme.  NXII  Nucleus  hypoglossi.  Ncu  Nucleus 
funiculi  cuneati.  Ng  Nucleus  funiculi  gracilis.  Fnc  Fasciculus  cuneatus.  m  Fasciculus 
longitudinalis  dorsalis.  Sgl  Substantia  gelatinosa  trigemini.  VLL  Nervus  facialis.  LX 
Nervtis  glossopharyngeus.  NX  Nucleus  vagi  dorsalis.  LXa  Radix  spinalis  glossopharyngei. 
BPo  Brachium  pontis. 


ii4  \OX-ACOUSTIC  OR  STATIC  LABYRINTH. 

the  long  axis  of  the  ridge  is  at  right  angles  to  the  long  axis  of  the  canal. 
The  ridge  is  built  up  of  a  fan-like  separation  of  the  ampullar  nerve  fila- 
ments plus  connective  and  vascular  tissues.  The  nerve  filaments  ter- 
minate in  the  special  sense  end-organ  (crista  ampullaris). 

The  crista?,  like  the  maculae,  are  composed  of  ciliated  neuro-epithelial 
and  supporting  cells.  The  ciliated  cells  are  the  real  special  sense  or 
perceiving  cells.  These  differ  from  those  of  the  maculae  in  that  they 
carry  much  longer  cilia. 

The  supporting  cells  of  the  cristse  no  doubt  perform  a  similar  func- 
tion to  the  supporting  cells  of  the  maculae. 

The  cilia  are  held  more  or  less  together,  or  so  to  speak  matted  to- 
gether, by  a  mucilaginous  substance  in  such  manner  that  their  distal 
tips  come  close  together,  much  like  a  paint  brush  after  dipping  in  oil, 
and  looks  not  unlike  it.  On  the  summit  of  the  cilia  is  an  accumulation 
of  the  mucilaginous  or  gelatinous  substance  which  is  known  as  the 
cupula  terminalis.  The  cilia  are  more  or  less  flexible  and  capable  of 
inclination  in  two  directions — toward  and  away  from  the  utriculus  in 
the  long  axis  of  the  canals.  Because  of  the  matting  together  of  the 
cilia  they  all  move  in  one  or  the  other  direction  as  a  single  mass. 

All  of  these  five  end  organs  receive  their  nerve  supply  from  branches 
of  the  vestibular  nerve,  the  course  of  which  according  to  Obersteiner 
and  Marburg  is  as  follows: — the  peripheral  fibers  are  interrupted  and 
terminate  in  the  bipolar  ganglion  cells  (ganglion  vestibulare  or 
Scarpa's  ganglion).  From  this  ganglion  originate  central  fibers  which 
unite  into  a  thick  trunk  and  form  the  median  acusticus  root  (vesti- 
bular). This  root  of  VIII  N.  enters  the  medulla  oblongata  at  the  level 
of  the  olive,  just  medianward  of  the  nucleus  accessorius.  The  fibers 
then  pass  in  a  median  dorsal  direction  between  the  corpus  resti forme 
and  the  spinal  trigeminus  root  to  the  nucleus  vestibularis  triangularis 
and  the  nucleus  vestibularis  magnocellularis.  The  latter  nucleus  com- 
prising Deiter's  and  Bechterew's  nuclei.  (Figs.  10  and  n.) 

The  nucleus  triangularis  and  the  nucleus  magnocellularis  lie  on  the 
floor  of  the  fourth  ventricle ;  the  nucleus  triangularis  somewhat  more 
medianward  and  nearer  the  floor  of  the  ventricle  than  the  nucleus 
magnocellularis. 

From  the  triangularis  nucleus  go  ascending  and  descending  fibers. 

From  the  nucleus  magnocellularis  go  both  crossed  and  uncrossed, 
ascending  and  descending  fibers.  The  ascending  fibers  form  the  pos- 
terior longitudinal  bundle — fasiculus  longitudinalis  dorsalis  of  Schulz, 


LABYRINTH  PAPERS.  115 

and  are  in  direct  communication  with  the  nuclei  of  the  VI,  IV  and  III 
nerves.  It  is  this  part  of  the  so-called  Deiter's  system  which  has  to 
do  with  vestibular  reflex  nystagmus. 

Descending  fibers  from  the  nucleus  magnocellularis  go  to  the  motor 
cells  of  the  anterior  horns  of  the  spinal  cord,  and  they  play  a  part  in  the 
co-ordination  of  the  trunk  and  leg  muscles. 

Furthermore  from  the  nuclei  vestibuli  magnocellularis  et  triangularis 
go  fibers  by  the  tractus  nucleocerebellaris  to  the  cerebellum.  These 
fibers  terminate  in  the  nuclei  tecti  of  the  same  and  opposite  side,  and  ac- 
cording to  some  authors  to  the  cortex  of  the  cerebellum. 

RELATIVE    POSITIONS   OF   THE   SEMICIRCULAR   CANALS. 

The  writer  considers  the  relative  position  of  the  semicircular  canals 
to  the  skull  and  to  each  other  a  subject  of  some  importance,  since  quite 
a  number  of  men  (beginners)  with  whom  he  has  spoken  concerning  the 
labyrinth  have  had  the  erroneous  impression  that  the  lateral  or  hori- 
zontal canals  lie  in  the  horizontal,  the  superior  canal  in  the  frontal  and 
the  posterior  in  the  sagittal  planes  of  the  skull,  and  these  same  men  are 
prone  to  associate  horizontal  nystagmus  with  the  horizontal  canals, 
rotatory  nystagmus  with  the  superior  canals  and  vertical  nystagmus 
with  the  posterior  canals.  For  this  and  other  reasons  he  feels  it  neces- 
sary to  describe  and  illustrate  the  realtive  positions  of  the  canals. 

In  the  erect  position  of  the  head  the  external  canals  lie  practically 
in  the  horizontal  plane :  furthermore,  the  planes  of  the  two  sides  are 
one  and  the  same.  If  the  lateral  canals  of  the  two  sides  were  united 
they  would  make  a  complete  circle,  the  two  smooth  ends  meeting  and 
blending  posteriorly  and  the  two  ampullae  coming  together  anteriorly. 

The  two  superior  canals  lie  in  vertical  planes,  but  unlike  the  external 
canals,  they  are  neither  in  the  same  nor  parallel  planes;  but  on  the 
contrary,  the  planes  of  the  canals  of  the  two  sides  are  at  right  angles 
to  each  other,  the  planes  meeting  in  the  median  line  posteriorly  at  the 
point  P,  at  the  posterior  margin  of  the  foramen  magnum.  Again,  when 
the  canals  of  the  two  sides  are  united  we  do  not  have  the  arrangement 
(blending  of  the  smooth  ends  and  meeting  of  the  ampullar  ends)  as  in 
the  case  of  the  external  canals. 

The  two  posterior  canals  lie  in  vertical  planes  at  right  angles  to  each 
other,  meeting  at  the  point  A — Fig.  12 — in  the  median  line  in  the  region 
of  the  sella  tursica.  Again,  if  these  canals  were  united  we  would  not 
have  the  same  arrangements  as  in  the  case  of  the  external  canals. 


ii6  NON-ACOUSTIC  OR  STATIC  LABYRINTH. 

When  considering  the  two  superior  or  two  posterior  canals  together 
there  is  a  lack  of  congruity  or  association  which  we  find  existing  in 
the  case  of  the  two  external  canals.  On  the  other  hand,  if  we  consider 
the  superior  canal  of  one  side  with  the  posterior  canal  of  the  opposite 


Figure  12. — Half  schematic  representation  of  the  two  labyrinths  showing  the 
relative  positions  of  the  semicircular  canals  to  the  skull  and  to  each  other. 

N — 7th  and  8th  nerves  as  they  enter  the  internal  auditory  foramen.  C — Coch- 
lea. F — Geniculate  ganglion  of  the  facial  nerve.  E — External  semicircular 
canal.  The  dashed  line  i-i  illustrates  the  vertical  plane  of  the  left  superior 
semicircular  canal.  The  dashed  line  2-2,  the  vertical  plane  of  the  right  posterior 
semicircular  canal.  The  dotted  line  3-3  represents  the  vertical  plane  of  the  left 
posterior  semicircular  canal.  The  dotted  line  4-4  represents  the  vertical  plane  of 
the  right  superior  semicircular  canal.  A — The  point  of  meeting  of  the  vertical 
planes  of  the  posterior  semicircular  canals  of  the  two  sides.  P — The  point  of 
meeting  of  the  vertical  planes  of  the  superior  semicircular  canals  of  the  two  sides. 

side,  their  association  as  found  in  the  external  canals  is  established. 
In  other  words,  they  lie  in  parallel  planes,  and  if  the  canals  are  brought 
together  they  would  form  a  circle  with  the  smooth  ends  coming  to- 
gether and  blending,  while  the  two  ampullae  would  meet  at  a  point  180° 
from  the  smooth  ends.  Thus  we  see  that  the  six  canals  of  the  two 
sides  are  correllated  and  designed  after  a  definite  plan. 


PHYSIOLOGY  AND  PATHOLOGY  OF  THE  NONACOUSTIC 
OR,   SO-CALLED,   STATIC   LABYRINTH. 

NYSTAGMUS. 

BEFORE  considering  that  special  form  of  nystagmus  which  may 
be  produced  physiologically  by  irritation  of  the  nonacoustic 
labyrinth  or  pathologically  by  irritative  or  destructive  changes 
in  the  same,  let  us  briefly  consider  the  subject  of  nystagmus  in  general 

Nystagmus  is  an  involuntary  to  and  fro  movement  of  the  eyes,  sub- 
ject in  some  instances  to  more  or  less  voluntary  inhibition. 

According  to  the  plane  in  which  the  movements  take  place  we  have 
horizontal,  rotatory,  vertical  or  oblique  nystagmus ;  or  any  combina- 
tion of  these.  According  to  the  comparative  rapidity  of  the  two  move- 
ments (to  and  fro)  we  have  the  oscillatory  and  rhythmic  forms  of 
nystagmus. 

In  the  case  of  oscillatory — also  known  as  undulatory — nystagmus 
the  two  component  eye  movements  or  excursions  are  performed  with 
equal  rapidity,  just  as  in  the  case  of  the  pendulum  of  a  clock,  the  oscil- 
lation to  one  side  is  performed  with  precisely  the  same  rapidity  as  the 
oscillation  to  the  opposite  side.  For  this  reason  we  cannot  speak  of 
oscillatory  nystagmus  taking  place  in  any  definite  direction.  We  may 
speak  of  a  horizontal  oscillatory  nystagmus,  but  it  would  be  nonsense 
to  speak  of  a  horizontal  oscillatory  nystagmus  to  the  right  or  to  the  left. 

In  the  case  of  rhythmic  nystagmus  the  two  component  eye  move- 
ments are  performed  with  unequal  rapidity;  in  other  words,  the  eye 
movements  are  jerky  or  spasmodic  in  one  direction  and  slow  in  the 
opposite;  for  this  reason  we  may  consistently  speak  of  horizontal 
rhythmic  nystagmus  to  the  right  or  left. 

Authors  have  agreed  to  specify  the  direction  of  rhythmic  nystagmus 
according  to  the  direction  of  the  rapid  movement;  thus  horizontal 
nystagmus  to  the  right  is  understood  to  be  rhythmic  and  not  oscillatory, 
from  the  fact  that  a  definite  direction  is  specified ;  the  plane  of  the 
movements  is  horizontal  and  the  direction  of  the  quicker  movements  is 
to  the  right. 

For  the  sake  of  convenience  the  plane  and  direction  of  rhythmic 
nystagmus  may  be  indicated  by  appropriate  signs,  as  follows : 


n8 


NON-ACOUSTIC  OR  STATIC  LABYRINTH. 


\ 

N 


L.  Horizontal  nystagmus  to  the  patient's  left. 

R.  Horizontal  nystagmus  to  the  patient's  right. 

L.  Rotatory  nystagmus  to  the  patient's  left. 

R.  Rotatory  nystagmus  to  the  patient's  right. 

U.  Vertical  nystagmus  upward. 

D.  Vertical  nystagmus  downward. 

U.  L.     Oblique  nystagmus  upward  and  to  the  patient's  left. 

D.  R.     Oblique  nystagmus  downward  and  to  the  patient's  right. 

D.  L.     Oblique  nystagmus  downward  and  to  the  patient's  left. 

U.  R.     Oblique  nystagmus  upward  and  to  the  patient's  right 


The  directions  indicated  by  the  arrows  above  correspond  to  the 
directions  of  the  eye  movements  as  seen  by  the  observer  looking  directly 
at  the  patient,  from  in  front.  These  signs  are  the  author's,  modified 
after  Barany,  and  have  been  adopted  and  used  by  Alexander  and  his 
staff  in  the  ear  department  of  the  Polyclinic  in  Vienna. 

It  is  well  at  this  time  to  differentiate  still  further  the  oscillatory  and 
rhythmic  forms  of  nystagmus,  including  a  review  of  the  points  already 
mentioned. 


OSCILLATORY    NYSTAGMUS. 

I — May  take  place  in  any  plane. 

2 — The  two  opposite  movements 
occur  with  equal  rapidity. 

3 — We  cannot  speak  of  a  definite 
direction  of  this  nystag- 
mus. 

4 — Cannot  be  produced  experi- 
mentally. 


RHYTHMIC   NYSTAGMUS. 

I — May  likewise  take  place  in 
any  plane. 

2 — The  two  opposite  movements 
occur  with  unequal  rapid- 
ity. 

3 — We  may  speak  of  a  definite 
direction,  corresponding  to 
the  direction  of  the  rapid 
movement. 

4 — May  be  produced  experi- 
mentally by  active  or  pass- 
ive rotations,  by  caloric, 
mechanical  or  galvanic  ir- 
ritation of  the  ear  laby- 
rinth (vestibular)  ;  or  by 
the  looking  out  of  a  mov- 
ing train,  looking  at  a 
waterfall,  etc.  (optical.) 


LABYRINTH  PAPERS. 


1 19 


5 — Is     not     accompanied     with 
vertigo. 

6 — Is  ahvays  of  pathologic  sig- 
nificance. 


7 — The  intensity  can  be  volun- 
tarily inhibited,  and  in 
some  cases  even  to  the  ex- 
tent of  bringing  about 
temporary  cessation.  The 
inhibition  of  the  nystag- 
mus is  in  direct  proportion 
to  the  inhibition  of  the  at- 
tempt at  central  visual  fix- 
ation. 

8 — Oscillatory  nystagmus  is 
practically  a  permanent 
pathologic  condition,  and 
tends  in  some  cases  to  in- 
crease. 

9 — Oscillatory  nystagmus,  in 
some  cases,  has  been  ob- 
served to  take  on  a  some- 
what rhythmic  character 
during  attempts  at  fixa- 
tion in  extreme  lateral  po- 
sitions. 


5 — Is  generally  accompanied 
with  vertigo,  at  least  when 
the  nystagmus  first  occurs. 

6— Is  not  always  of  pathologic 
significance,  since  it  may 
be  produced  physiologic- 
ally by  attempts  at  volun- 
tary fixation  of  the  gaze  in 
any  extreme  direction.  Be- 
sides, most  optical  forms 
(see  above)  are  generally 
physiologic. 

7 — The  intensity  of  the  nystag- 
mus can  be  inhibited  only 
by  the  patient  looking  in 
the  opposite  direction  to  his 
nystagmus.  A  pronounced 
nystagmus  to  the  right 
when  looking  to  the  right 
cannot  be  inhibited  so  long 
as  the  patient  continues  to 
look  in  that  direction. 

8 — Rhythmic  nystagmus  is  gen- 
erally a  transient  condi- 
tion, and  tends  rather  to 
dimmish  and  may  even 
cease  in  some  cases. 

9 — On  the  contrary,  rhythmic 
nystagmus  cannot  be  made 
to  take  on  an  oscillatory 
character. 


Nystagmus  is  almost  always  bilateral.  In  exceptional  cases  we  find 
it  unilateral ;  in  other  exceptional  cases,  tho  the  nystagmus  is  bilateral 
and  synchronous,  the  length  of  the  nystagmic  excursions  are  unequal 
in  the  two  eyes.  In  this  connection  the  writer  will  cite  three  cases 
illustrating  these  variations. 


120  NO\' -ACOUSTIC  OR  STATIC  LABYRINTH. 

CASE  I. — A  woman  about  50  years  of  age,  with  both  labyrinths 
normal,  was  examined  upon  the  revolving  stool.  After  ten  complete 
turns  to  the  left  with  the  head  in  the  upright  position,  instead  of  mani- 
festing a  bilateral  horizontal  after-nystagmus  to  the  right — as  the  vast 
majority  of  cases  do — she  manifested  a  horizontal  after-nystagmus  to 
the  right  of  the  right  eye  only,  the  left  eye  remaining  stationary.  The 
same  results  were  obtained  when  turned  in  the  opposite  direction,  ;.  r., 
after-nystagmus  to  the  left  of  the  left  eye  only,  the  right  eye  remaining 
stationary. 

With  the  caloric  test  the  same  character  of  reactions  was  obtained, 
namely,  unilateral  nystagmus  and  always  of  the  eye  of  the  side  to 
which  the  nystagmus  manifested  itself. 

CASE  II. — A  woman,  aged  40,  of  low  intelligence,  after  the  turning 
test  (as  above  described)  manifested  instead  of  nystagmus  a  deviation 
of  one  eye.  For  instance :  Instead  of  manifesting  a  bilateral  nystag- 
mus to  the  right  by  the  various  tests  which  produce  nystagmus  to  the 
right,  she  manifested  a  deviation  of  the  right  eye  to  the  left,  in  other 
words,  a  convergent  strabismus  of  the  type  corresponding  to  paralysis 
of  the  right  external  rectus.  The  deviation  endured  for  a  length  of 
time  corresponding  to  a  nystagmus  reaction  in  the  average  normal 
individual. 

CASE  III. — A  young  man  21  years  old,  with  diffuse  corneal  opacity 
in  the  right  eye  and  slight  microphthalmos  of  the  same  eye,  manifests 
a  pronounced  spontaneous  rhythmic  nystagmus  of  the  right  eye  to  the 
left ;  while  the  left  normal  eye  manifests  a  barely  perceptible  nystag- 
mus synchronous  with  that  of  the  right  eye. 

ETIOLOGY   OF   OSCILLATORY    NYSTAGMUS. 

Oscillatory  nystagmus  is  usually,  if  not  always,  due  to  congenital  or 
early  acquired  visual  defects ;  especially  central  visual  defects.  We 
therefore  find  it  prone  to  occur  in  cases  of  centrally  located  opacities 
of  the  ocular  media  (central  corneal  macula,  etc.)  and  in  cases  of 
fundus  disease  where  the  lesion  involves  the  region  of  the  macula 
lutea,  more  especially  when  these  conditions  have  occurred  before 
or  about  the  age  at  which  a  child  learns  to  fix  the  eyes  for  central 
vision.  In  other  words,  the  more  central  the  visual  defect  and 
the  earlier  in  life  it  occurs,  the  more  likely  the  child  is  to  develop 
oscillatory  nystagmus.  While  the  above  conditions  favor  most  the  de- 
velopment of  oscillatory  nystagmus,  we  find  cases  developing  later  in 
life.  We  also  find  rare  cases  of  congenital  oscillatory  nystagmus  oc- 
curring in  individuals  where  every  method  of  examination  fails  to 
reveal  any  pathologic  condition  of  the  eyes ;  but  on  the  other  hand,  they 
show  at  least  some  defect  of  central  vision.  The  cause  in  these  latter 
cases  is  unknown ;  however,  it  is  possible  that  at  some  future  time  they 


LABYRINTH  PAPERS.  121 

may  be  found  to  result  from  some  congenital  hemorrhage  or  other 
character  of  lesion  in  the  tracts  or  centers  corresponding  to  central 
macular  vision. 

While  oscillatory  nystagmus  results  from  congenital  or  early  ac- 
quired visual  defects,  not  every  case  of  congenital  or  early  acquired 
visual  defect  produces  the  oscillatory  form  of  nystagmus,  for  we  find 
cases  where  the  resulting  nystagmus  is  rhythmic  in  character.  The 
writer  has  examined  such  cases  for  the  purpose  of  determining  the 
presence  of  other  factors  that  might  have  caused  the  nystagmus  to  Be 
rhythmic  instead  of  oscillatory  in  character,  but  with  negative  results. 

Concerning  the  exact  causes  in  all  cases  of  oscillatory  nystagmus  we 
have  yet  much  to  learn.  Fortunately  for  the  otologist,  the  causes  of 
rhythmic  nystagmus  have  been  more  definitely  ascertained. 

ETIOLOGY   OF  RHYTHMIC   NYSTAGMUS. 

Rhythmic  nystagmus  may  be  produced  physiologically,  pathologic- 
ally or  experimentally. 

Physiologically,  as  already  pointed  out,  by  looking  out  of  a  moving 
car  window  at  passing  objects  (horizontal  nystagmus  to  the  left  when 
looking  out  of  the  right  side  of  the  car  which  is  moving  forward)  ;  by 
looking  out  of  elevator  car  (vertical  nystagmus  upward  when  car  is 
going  up,  and  vertical  nystagmus  downward  when  car  is  going  down). 
Again,  these  same  nystagmi  may  be  produced  physiologically  by  one 
remaining  stationary  and  observing  moving  objects — waterfalls  (verti- 
cal upward),  moving  carousal  (horizontal  to  the  right  when  the 
carousal  is  moving  to  the  left  past  our  field  of  vision,  etc.).  All  of 
these  represent  physiological  optical  nystagmus. 

Rhythmic  nystagmus  may  be  produced  physiologically  also  by  active 
or  passive  rotation  of  the  head  in  any  plane.  Barany  has  found  that  a 
single  rotation  will  produce  nystagmus  in  the  plane  of  rotation  and  in 
the  direction  of  rotation  during  the  turning,  even  with  the  eyes  closed. 
With  the  eyes  open  the  nystagmus  produced  by  rotation  represents  a 
combined  optical  and  vestibular  nystagmus;  with  the  eyes  closed  it 
represents  purely  vestibular  nystagmus. 

The  nystagmus  manifested  by  attempts  at  fixation  of  the  eyes  in  ex- 
treme positions  may  in  a  sense  be  termed  physiologic.  For  instance  all 
normal  individuals  when  looking  to  the  extreme  right  or.  left  manifest 
rhythmic  nystagmus  to  that  particular  side.  This  nystagmus  is  due  to 
the  extra  strain  put  upon  the  abductors  of  one  eye  and  the  adductors 
of  the  other  eye,  and  compares  with  the  clonic  contractions  of  other 


122  NON-ACOUSTIC  OR  STATIC  LABYRINTH. 

body  muscles  when  any  extra  strain  is  put  upon  them.  This  nystagmus 
is  dependent  upon  two  contrary  working  factors :  ( I )  the  strong  vol- 
untary cortical  impulse  to  the  muscles,  and  (2)  the  inherent  weakness 
of  the  muscles  to  maintain  the  excessive  muscular  contraction.  The 
contractions  are  intermittent,  with  the  result  that  the  individual  mani- 
fests nystagmus.  This  form  of  nystagmus  varies  in  different  indi- 
viduals;  for  instance,  those  with  weak  eye  muscles  and  with  strong 
power  for  voluntary  cortical  innervation  will  manifest  a  more  marked 
nystagmus  than  those  with  stronger  muscles  and  weaker  power  of 
innervation.  It  is  characteristic  for  nystagmus  of  this  type  to  manifest 
itself  with  equal  intensity  to  both  sides. 

The  knowledge  of  all  these  facts  is  important  and  will  save  much 
confusion  when  we  come  to  consider  the  observations  of  vestibular 
nystagmus. 

Rhythmic  nystagmus  may  be  produced  pathologically  by  unilateral, 
irritative  or  destructive  conditions  of  the  labyrinth,  the  vestibular  nerve, 
its  nucleus  in  the  medulla,  the  supranuclear  tracts  (posterior  longitudi- 
nal bundle  and  tractus  nucleo-cerebellaris)  or  of  the  cerebellum  itself, 
which  involve  the  sensory  or  centripetal  impulses.  Again,  rhythmic 
nystagmus  may  be  produced  pathologically  by  irritative  or  destructive 
lesions — of  the  supranuclear  motor  tract  (including  the  posterior  longi- 
tudinal bundle,  which  is  really  more  motor  than  sensory),  the  cortico- 
nuclear,  equivalent  to  the  pyramidal  tract,  the  motor  nuclei,  the  motor 
nerves  or  the  eye  muscles  themselves — which  involve  the  motor  or 
centrifugal  impulses. 

Besides  the  location,  the  nature  of  the  lesions  capable  of  producing 
nystagmus  are  numerous. 

These  two^conditions  (location  and  character  of  the  lesion)  taken 
together  multiply  the  number  of  possible  pathologic  processes  capable 
of  producing  rhythmic  nystagmus,  some  of  which  may  be  cited,  e.  g.: 
any  form  of  lesion  of  the  labyrinth ;  hyperemia,  inflammation ;  fist- 
ula ;  traumatism,  direct  and  indirect,  involving  the  labyrinth  capsule 
and  including  fracture  at  the  base  of  the  skull  passing  thru  the 
pyramid ;  hemorrhages  into  the  labyrinth  from  chlorosis,  pernicious 
anemia,  from  changes  in  atmospheric  pressure  in  caisson  workers, 
balloonists,  etc. ;  ischemia  from  embolism  or  partial  obliteration  of  the 
arteria  auditivae  internae  in  arteriosclerosis  and  endarteritis ;  toxemias 
from  quinine,  salicylates,  etc. ;  granulomatous  infiltration  of  syphilis, 
tuberculosis  and  leukemia. 

Diseases  of  the  vestibular  nerve :  neuritis ;  tumor ;  granulomatous 


LABYRIXTH  PAPERS.  123 

infiltration ;  basal  meningitis ;  increased  intracranial  pressure  in  case  of 
acute  hydrocephalus,  cerebral  tumors  and  abscess. 

Diseases  of  the  medulla  oblongata  involving  the  vestibular  nuclei 
(triangularis  and  magnocellularis),  including  bulbar  and  pseudobulbar 
palsy,  tumors,  syphilis,  tuberculosis,  hemorrhage,  multiple  sclerosis ; 
toxic  substances  circulating  in  the  blood  stream  (alcohol,  nicotine,  ex- 
cess of  carbon  dioxid,  etc.). 

Diseases  of  the  cerebellum :  tumors,  abscess,  areas  of  multiple  sclero- 
sis, etc. 

Diseases  of  the  posterior  longitudinal  bundle :  tumors,  gummatous 
or  tuberculous  infiltrations  on  the  floor  of  the  fourth  ventricle  (above 
the  striae  acousticae)  or  the  aqueductus  silvii,  multiple  sclerotic  plaques, 
etc. 

Diseases  of  the  eye  muscle  nuclei:  tumors,  hemorrhages,  degenera- 
tions, abscess,  sclerosis,  emboli,  arteriosclerosis,  etc. 

Diseases  of  the  motor  nerves  of  the  eye  muscles :  neuritis  from  vari- 
ous causes  (refrigeratory,  postinfectious,  toxic,  luetic,  etc.),  tumors 
and  granulomatous  infiltrations,  orbital  fractures  and  intraorbital  dis- 
ease which  might  impair  the  innervation  or  action  of  a  particular 
muscle  or  set  of  muscles. 

The  writer  has  merely  mentioned  some  of  the  pathologic  causes ; 
there  are  perhaps  as  many  more,  including  the  yet  undiscovered,  that 
may  produce  rhythmic  nystagmus. 

It  might  be  said  in  this  conjunction  that  the  nystagmus  of  cerebellar 
disease  is  not  a  real  ataxia  nor  is  it  homologous  to  the  ataxia  mani- 
fested in  the  extremities  or  trunk,  as  might  be  believed,  but  is  a  true 
rhythmic  nystagmus.  Marburg  and  others,  including  the  writer,  be- 
lieve that  the  nystagmus  of  cerebellar  disease  is  actually  vestibular  in 
type  and  originates  from  influences  acting  directly  upon  Deiter's 
nucleus,  which  lies  in  the  immediate  neighborhood  of  the  lateral  cere- 
bellar  lobe. 

Experimentally  optical  nystagmus  can  be  produced  by  the  rota- 
tions of  objects  in  various  planes  before  the  open  eyes  (experi- 
ments similar  to  those  made  by  Mach)  or  by  passive  rotations  of  the 
individual  in  various  planes  about  stationary  surroundings.  In  this 
latter  instance  the  resulting  rotational  nystagmus  is  produced  by  a 
combination  of  two  irritations:  (i)  the  passage  of  moving  objects  be- 
fore the  open  eyes  (optical),  and  (2)  motion  of  the  endolymph  in  the 
semicircular  canals  (vestibular).  The  elimination  of  the  vestibular 
element  and  the  production  of  pure  optical  rotational  nystagmus  after 


124  NON-ACOUSTIC  OR  STATIC  LABYRINTH. 

the  above  method  is  possible  only  in  those  cases  of  deaf  mutes  which 
have  complete  destruction  of  both  labyrinths  or  nerves.  The  elimination 
of  the  optical  element  and  the  production  of  pure  vestibular  rotational 
nystagmus  is  possible  by  the  simple  closure  of  the  eyes  during  the 
rotations.  In  fact,  this  was  one  of  the  earlier  methods  of  examination 
for  rotational  vestibular  nystagmus,  the  determination  of  which  was  ac- 
complished, during  the  turning,  by  feeling  of  the  eye  movements  with 
the  fingers  thru  the  closed  lids. 

Experimentally,  vestibular  nystagmus  can  be  produced  in  man  by 
active  and  passive  turnings,  by  caloric  irritation  of  the  labyrinth  and  by 
galvanic  irritation  of  the  labyrinth  and  nerve,  or  by  mechanical  irrita- 
tion as  practiced  first  by  Ewald  and  later  by  Dreyfuss. 


Sketch  After  Barany. 

Ewald,  1888  (Zur.  Physiologic  der  Bgg. — Tageblatt  de  61  Ver- 
sammlung  Deutscher  Naturforscher  u.  Aerste  in  Koeln,  von  18-23, 
Sept.,  1888,  s.  74-76),  described  for  the  first  time  his  experiments  upon 
pigeons  made  with  his  celebrated  pneumatic  hammer.  This  experi- 
ment was  unique  in  the  history  of  the  subject  and  a  description  of  his 
hammer  and  methods  of  applying  it  is  well  worth  citing. 

Ewald  first  exposed  and  prepared  the  osseous  external  semicircular 
canal  of  a  pigeon.  He  then  drilled  a  small  opening  thro  it  several  mm. 
posterior  to  the  ampulla,  at  the  same  time  avoiding  injury  to  the  mem- 
branous canal.  Through  this  opening  he  inserted  a  filling  material 
similar  to  that  used  by  dentists,  which  when  it  becomes  set  acted  as  a 
plug  interrupting  completely  the  lumen  of  the  membranous  canal  at  this 
point  (a). 


LABYRINTH  PAPERS.  125 

Xext  he  made  a  second  small  opening  after  the  manner  of  the  first 
midway  between  the  first  opening  and  the  ampulla.  At  the  second 
opening  he  adjusted  an  apparatus  known  as  a  pneumatic  hammer.  This 
hammer  consists  of  a  slender  glass  cylinder  open  at  both  ends,  inside  of 
which  glides  a  piston  with  a  small  button  on  its  distal  end,  which  comes 
in  contact  with  the  membranous  canal  and  serves  to  give  it  the  hammer 
effect.  Over  the  other  end  of  the  glass  cylinder  is  fitted  a  rubber  tube 
of  convenient  length  and  on  the  end  of  this  again  is  fitted  the  rubber 
bag  (§)•  Compression  of  the  bag  held  in  the  hand,  drives  the  piston 
inward  against  the  membranous  canal.  Relaxation  of  pressure  on  the 
bag  produces  aspiration,  causing  the  piston  to  be  withdrawn  to  its  pri- 
mary position.  When  the  piston  is  driven  inward  by  compression  the 
displaced  endolymph,  since  it  cannot  flow  posteriorly  on  account  ot  the 
plug  (a),  must  flow  anteriorly  toward  the  ampulla  and  utriculus  in- 
dicated by  the  arrow.  On  the  other  hand,  by  aspiration  the  endo- 
lymph must  flow  in  the  opposite  direction.  Ewald,  after  this  manner 
oi  examination,  found  that  compression,  equivalent  to  movement  of 
endolymph  from  the  nonampullar  toward  the  ampullar  end,  caused  a 
slow  movement  of  the  eyes  and  head  to  the  opposite  side  in  the  plane 
of  the  canal  (horizontal)  ;  and  that  aspiration,  equivalent  to  a  move- 
ment of  the  endolymph  from  the  ampullar  toward  the  nonampullar 
end,  caused  a  slow  movement  of  the  eyes  and  head  to  the  same  side. 

From  this,  Ewald  was  able  to  conclude  that  definite  movements  of 
the  endolymph  in  the  horizontal  canal  were  responsible  for  definite  re- 
flex movements  of  the  head  and  eyes.  Ewald  after  the  same  manner 
demonstrated  the  characteristic  movements  of  the  head  and  eyes  cor- 
responding to  definite  endolymph  movements  in  the  remaining  canals. 

The  physiology  of  vestibular  nystagmus  produced  by  turning  and  the 
caloric  irritation  of  the  labyrinth  differs  from  that  produced  by  gal- 
vanism. Before  discussing  the  physiology  of  nystagmus  produced  by 
these  separate  irritations,  let  us  consider  the  physiology  of  vestibular 
nystagmus  in  general. 

PHYSIOLOGY   OF   THE  TWO   MOVEMENTS   OF   NYSTAGMUS. 

It  is  a  well  known  and  established  fact  that  irritation  of  the  semi- 
circular canals  of  one  side  will  produce  nystagmus  to  that  side  and 
that  the  inhibition  of  impulses  from  the  semicircular  canals  of  one  side 
will  produce  nystagmus  to  the  opposite  side.  Let  it  be  understood  early 
that  nystagmus  produced  by  either  irritation  or  inhibition  is  not  the 
actual  vestibular  reflex,  but  merely  the  evidence  of  the  reflex.  The 


126  NON-ACOUSTIC  OR  STATIC  LABYRINTH. 

actual  reflex,  from  irritation,  for  instance,  of  the  right  semicircular 
canals,  produces  a  deviation  of  the  eyes  to  the  left,  while  the  quick, 
jerky  movements  of  the  eyes  to  the  right  (Einstellung  of  the  German 
authors)  is  the  result  of  a  voluntary  effort  on  the  part  of  the  individual 
to  restore  macular  fixation  of  external  objects  which  had  been  t°m- 
porarily  lost  during  the  reflex  deviation  of  the  eyes. 

To  better  show  the  physiology  of  the  two  movements  of  nystagmus 
the  writer  will  make  use  of  an  illustration  from  Barany's  work  upon 
the  Phys.  and  Path,  des  Bgg.  Appar.  beim  Menschen,  page  53.  See 
Fig.  14. 

There  is  an  abundance  of  evidence  to  show  that  the  conjugate  devia- 
tion of  the  eyes  (slow  movement  of  the  nystagmus)  is  the  actual  vestib- 
ular  reflex,  and  that  the  rapid  movements  in  the  opposite  direction  arc 
purely  voluntary,  produced  by  cortical  innervation. 

In  the  making  of  various  animal  experiments  by  sectioning  of  the 
canals,  by  sectioning  of  the  acusticovestibular  nerve,  by  mechanical 
(Ewald's  pneumatic  hammer  experiment)  or  by  galvanic  irritations  of 
the  semicircular  canals,  it  has  been  found  that  some  animals  show  only 
the  reflex  deviation  (correspondng  to  the  slow  movements  of  the 
nystagmus)  to  the  opposite  or  nonirritated  side,  while  others  will  show 
rhythmic  nystagmus  to  the  same  dr  irritated  side.  Again,  the  same 
animal  will  show  by  the  same  experiment  at  one  time  deviation  and  an- 
other time  nystagmus.  Frequently  the  nystagmus  will  be  more  pro- 
nounced immediately  after  the  irritation  or  destruction,  whereas  later, 
as  the  animal  tires,  it  will  show  only  the  deviation.  Furthermore,  it 
will  be  found  that  the  lower  the  animal  the  weaker  is  the  volition  and 
the  more  likely  it  is  to  show  only  the  reflex  deviation ;  while  the  higher 
the  animal,  the  stronger  is  the  volition  and  the  more  likely  it  is  to  show 
nystagmus. 

Again,  if  one  experiments  with  a  sufficient  number  of  human  sub- 
jects he  will  observe  quite  a  difference  in  different  individuals.  It  will 
be  observed  that  the  more  intelligent  people  will  show  the  more  pro- 
nounced nystagmus ;  while  occasionally  very  young  children  or  very 
stupid  people  of  low  intelligence  will  manifest  deviation  only.  When 
making  time  experiments  of  after-turning  nystagmus,  in  those  cases 
manifesting  deviation  only  it  is  important  to  time  the  duration  of  the 
deviation  just  as  one  would  in  another  case  time  the  duration  of 
nystagmus. 

Fig.  14  illustrating  horizontal  nystagmus  to  the  left  produced  by 
irritation  of  the  left  semicircular  canal  apparatus. 


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a,  a1  Nucleus  Deiters,  sinis,  et  dext.  b,  b1  Nucleus  nerv.  abducens,  sinist.  et 
dext.  c,  c1  Nucleus  nerv.  oculomotor,  sinist.  et  dext.  d,  d1  Oculus,  smist.  et 
dext,  e,  e1  Muse.  rect.  extern,  sinist.  et  dext,  f,  f1  Muse.  rect.  intern,  sinist.  et 
dext.  g,  Shaltzelle  (Monakow)  =  centre  for  the  movement  of  the  eyes  to  the 

left,     h,  Nervus  vest,  sinist.     i,  Vestibular  tract   ( )    crossing  to  the 

contralateral  abducens  nucleus,    k,  Vestibular  tract  ( )  crossing  to  the 

contralateral  oculomotorius  nucleus.    1,  Vestibular  inhibition  tract  ( ) 

to    the    homolateral    oculomotorius    nucleus.      m,    Vestibular    inhibition    tract 

(....• )  to  the  homolateral  abducens  nucleus,    n,  Gyrus  angularis  dextra 

(cortex),  center  for  the  voluntary  movement  of  the  eyes  to  the  left,  o,  Cortical 
tract  ( — .  — .  —  .  — .)  to  subcortical  center  (Monakow's)  for  the  voluntary 
movements  of  the  eyes  to  the  left,  p,  Supranuclear  tract  ( — .  — .  — .  —  .)  from 
the  left  subcortical  center  (Monakow's)  to  the  homolateral  oculomotorius 
nucleus,  q,  Supranucleur  tract  ( — .  — .  —  .  —  .)  from  the  left  cortical  voluntary 
center  (Monakow's)  to  the  homolateral  abducens  nucleus,  r,  A  double  sided 
lesion  at  r  would  produce  paralysis  of  voluntary  movements  of  the  eyes,  which 
at  the  same  time  would  leave  vestibular  nystagmus  undisturbed  (pseudo- 
ophthalmoplegia  of  Wernicke).  s,  A  double  sided  lesion  at  s  would  produce 
paralysis  of  voluntary  movements  of  the  eyes  and  make  impossible  the  quicker 
voluntary  movements  of  nystagmus,  but  would  leave  the  slow  vestibular  reflex 
movement  undisturbed  (supra/mclear  ophthalmoplegia  of  Barany). 


128  XOX-ACOUST1C  OR  STATIC  LABYRIXTH. 

A  further  illustration  of  the  voluntary  nature  of  the  quick  move- 
ment of  the  nystagmus  is  demonstrated  by  the  fact  that  the  nystagmus 
is  least  pronounced  when  the  patient  looks  toward  the  side  of  the  devia- 
tion and  most  pronounced  when  he  looks  toward  the  side  of  his 
nystagmus. 

An  interesting  and  instructive  case  cited  by  Ilarany  (Phys.  u.  Path, 
der  Bgg.  Appar.  beim  Menchen),  also  seen  by  the  writer,  practically 
settles  the  problem  of  the  physiology  of  the  two  movements  of  nystag- 
mus. The  case  is  as  follows : 

A  patient  was  referred  from  the  neurological  to  the  ear  department  of 
the  general  hospital  in  Vienna,  suffering  with  complete  paralysis  of 
abduction  and  adduction.  The  patient  could  not  voluntarily  move  the 
eyes  to  either  side,  because  of  a  supranuclear  lesion ;  but  upon  rotation 
and  caloric  irritation  of  the  semicircular  canals  the  patient  manifested 
a  reflex  conjugate  deviation  of  the  eyes  to  the  side  opposite  the  irrita- 
tion, without  nystagmus.  After  turning  there  was  conjugate  deviation 
of  the  eyes  to  the  same  side  without  nystagmus.  The  writer  might 
cite  many  other  circumstances,  including  experiments  made  upon  nar- 
cotized and  comatose  subjects,  to  prove  the  facts  originally  stated  that 
the  deviation  of  the  eyes  or  its  equivalent,  the  slow  movement  of  the 
nystagmus,  is  the  actual  vestibular  reflex,  while  the  quick  movement  in 
the  contrary  direction  is  voluntarily  produced. 

From  what  has  been  previously  said,  the  intensity  of  the  vestibular 
nystagmus  depends  upon  two  factors :  ( I )  the  intensity  of  the  irritation 
of  the  semicircular  canals  in  producing  the  reflex  deviation  of  the  eyes ; 
and  (2)  the  intensity  of  the  voluntary  cortical  innervation  to  re-estab- 
lish macular  fixation  of  external  objects.  For  these  reasons  the  in- 
tensity of  the  nystagmus  should  be  (exactly  as  we  find  it)  most 
marked  when  looking  in  the  direction  away  from  the  reflex  deviation 
(toward  the  nystagmus),  and  least  marked  when  looking  in  the  direc- 
tion toward  the  reflex  deviation  (away  from  the  nystagmus). 

ESTIMATION    OF    THE    INTENSITY    OF    THE    NYSTAGMUS. 

The  intensity  of  the  nystagmus  is  estimated  by  the  length  of  excur- 
sions of  the  eyes  and  the  frequency  of  these  excursions.  Thus  a 
nystagmus  of  six  mm.  excursion  is  more  intense  than  one  of  two  mm. 
Again,  a  frequency  of  six  excursions  per  second  is  more  intense  than 
one  of  two  excursions.  For  the  reason  that  the  rapidity  of  the  move- 
ments is  easier  to  estimate  than  the  length  of  the  excursions  the  custom 


LABYRINTH  PAPERS.  129 

has  been  to  judge  the  intensity  by  this  factor;  however,  the  amount  of 
deviation  of  the  eyes  measured  in  degrees  would  be  a  more  exact  but  a 
less  practical  method. 

HOW  SHOULD  OXE  EXAMINE  FOR   NYSTAGMUS? 

The  observation  of  nystagmus  is  quite  important.  Low  degrees  of 
rotatory  nystagmus  can  be  very  easily  overlooked  by  casual  observa- 
tion of  the  eyes  between  the  normal  palpebral  fissure,  and  the  more  so 
with  ordinary  illumination. 

The  writer  has  described  the  methods  of  examination  in  a  former 
paper  upon  "Labyrinth  Suppuration  ;  Two  Cases." 

The  first  requisite  is  good  illumination,  which  can  be  obtained  by  the 
use  of  any  ordinary  head  mirror.  It  is  well  to  direct  the  illumination 
sufficiently  obliquely  (from  the  side)  to  avoid  too  great  irritation  of  the 
macular  region  of  the  eye.  This  form  of  illumination  serves  another 
purpose,  that  of  producing  a  bright  reflex  on  the  upper  part  of  the 
sclera.  That  one  may  observe  the  eye  movements  to  the  best  advant- 
age it  is  necessary  to  elevate  the  upper  lid,  preferably  with  the  thumb 
of  the  left  hand  when  examining  the  right  eye  or  the  thumb  of  the 
right  hand  when  observing  the  left  eye.  Have  the  patient  look  at  some 
distant  object  in  the  horizontal  plane  or  slightly  above  it  and  directly  in 
front  of  him.  If  nystagmus  be  present,  the  eye  movements  can  be  not- 
ed by  change  of  relative  position  between  the  bright  reflex  produced  by 
your  concentrated  light  on  the  sclera  and  one  of  the  nearby  deep  con- 
junctival  or  long  ciliary  vessels  which  run  meridianally.  It  is  also  im- 
portant to  look  long  enough,  for  in  case  of  late  labyrinth  suppuration 
the  nystagmus  is  oftimes  so  slight  that  the  length  of  excursions  is  but 
one  or  two  mm.  at  most,  and  the  movements  may  repeat  themselves  at 
intervals  of  five  or  six  seconds  or  even  longer. 

The  object  of  having  the  patient  look  at  distant  objects  has  been 
pointed  out  by  Abels  and  quoted  by  the  writer  in  former  papers  upon 
the  subject.  When  looking  at  objects  at  close  range  the  necessary 
convergence  of  the  eyes  calls  for  so  strong  a  voluntary  innervation  of 
the  muscles  supplied  by  the  oculomotori  nuclei  and  nerves,  that  it  inter- 
feres and  inhibits  considerably  the  vestibular  reflex ;  again,  since  the 
nystagmus  is  diminished  in  proportion  to  the  convergence,  the  same 
patient  with  the  same  amount  of  irritation  in  the  semicircular  canals 
may  at  one  time  show  more  pronounced  reaction  than  at  subsequent 
times  when  the  oculomotori  were  more  strongly  innervated.  This  may 

9 


130  NON-ACOUSTIC  OR  STATIC  LABYRINTH. 

in  a  measure  account  for  some  of  the  wide  discrepancies  in  Barariy's 
earlier  figures,  especially  in  his  observations  of  after-turning  uystagmus. 
For  the  same  reason  the  observation  of  nystagmus  by  directing  the  pa- 
tient to  look  at  the  finger  held  to  the  sides  is  a  less  certain  method  than 
the  observation  of  nystagmus  after  the  manner  described  by  the  author. 
However,  in  some  exceptional  cases  the  examination  after  this  coarser 
method  (by  having  the  patient  to  look  to  the  side)  may  be  permissible, 
especially  in  demonstration  work  before  student  bodies. 


TURNING  AND  AFTER-TURNING  NYSTAGMUS. 

THUS  far  we  have  observed  that  vestibular  nystagmus  is 
rhythmic  in  character ;  that  it  is  designated  horizontal,  rota- 
tory, vertical,  etc.,  according  to  the  plane  of  its  move- 
ments ;  to  the  right,  to  the  left,  etc.,  according  to  the  direction 
of  the  quicker  excursion.  \Ye  have  further  observed  that  vestibular 
nystagmus  can  be  produced  by  a  one-sided  destruction  or  irritation  of 
certain  end-organs  in  the  semicircular  canals,  irritation  of  which  may 
be  produced  mechanically  (Ewald's  experiments)  by  turning,  by 
thermic  changes  and  by  galvanism. 

Of  mechanical  irritation  we  have  already  spoken  in  the  last  paper. 
In  the  present  paper  we  shall  discuss  the  subject  of  irritation  by  turn- 
ing and  after-turning. 

Physiologically  every  act  of  turning,  no  matter  how  slight,  is  ac- 
companied by  a  definite  amount  of  nystagmus ;  for  instance,  when  one 
turns  the  head  but  20  degrees,  the  eyes  make  a  double  movement ;  first 
a  slow  one,  in  the  direction  contrary  to  the  head  movement,  followed 
promptly  by  a  second  quicker  movement  in  the  same  direction. 

The  slow  movement  is  due  to  the  vestibular  reflex  which  permits  a 
brief  lingering  of  the  visual  fixation  upon  the  object  last  seen,  while 
the  quick  movement  is  due  to  a  second  fixation  upon  a  fresh  object. 
The  quicker  eye  movement  subtends  an  arc  equal  to  that  of  the  head 
movement. 

If  instead  of  stopping  at  20  degrees,  the  head  is  continued  in  rota- 
tion for  a  total  of  360  degrees  (thus  completing  the  circle)  it  will  be 
found  that  instead  of  a  single  slow  and  quick  movement,  as  in  the 
above  instance,  the  eyes  will  have  made  a  succession  of  such  move- 
ments. In  other  words,  the  subj'ect  will  have  manifested  a  rhythmic 
nystagmus  in  the  direction  of  rotation. 

The  total  amount  of  the  quick  eye  movements  equals  the  total 
amount  of  rotation  of  the  head.  During  each  slow  movement  there  is 
a  visual  impression  together  with  a  fixation  of  the  field,  which  appears 
to  be  constantly  passing  and  which  the  eyes  follow  in  the  direction  con- 
trary to  the  rotation  of  the  head.  During  the  quicker  movements 
there  is  neither  visual  impression  nor  fixation  of  the  field,  but  a  series 
of  interruptions  between  succeeding  visual  impressions.  In  brief, 


I32  TURXIXG  AXD   AFTER-TURX1XG  XYSTAGMUS. 

rhythmic  nystagmus  is  accompanied  by  a  series  of  alternate  visual  im- 
pressions and  interruptions  of  these  impressions. 

Thus  far  we  have  spoken  of  the  nystagmus  produced  by  rotation  of 
the  head  with  the  eyes  open,  the  effects  being  quite  similar  but  not 
identical  to  those  produced  by  the  rotation  of  the  field  about  the  sta- 
tionary subject,  the  difference  being,  in  the  case  of  rotation  of  the  field 
about  the  stationary  subject  the  production  of  rotational  optical 
nystagmus,  while  in  the  case  of  rotation  of  the  subject  with  open  eyes 
about  the  stationary  field,  the  production  of  combined  rotational  optical 
nystagmus  and  rotational  vestibular  nystagmus. 

In  order  to  produce  pure  rotational  or  turning  vestibular  nystagmus 
it  is  necessary  to  make  the  turning  with  the  eyes  closed,  whereby 
the  optical  factor  is  eliminated. 

The  demonstration  of  turning  vestibular  nystagmus  can  be  made  by 
feeling  the  eye  movements  thru  the  closed  lids  with  the  finger  tips ;  an 
experiment  made  by  Kreidl  and  others  which  can  be  repeated  easily  by 
anyone  upon  himself.  To  examine  another  person  it  would  be  neces- 
sary to  have  a  revolving  platform  sufficiently  large  to  accommodate  both 
the  subject  and  the  observer.  For  practical  purposes,  however,  this 
method  has  become  obsolete. 

With  every  movement  of  the  head,  with  closed  eyes,  there  occurs  the 
same  movements  of  the  eyes  as  when  the  eyes  are  open ;  the  physiology 
however  differs  as  has  been  stated.  This  then  leads  us  to  a  discussion 
of  the 

PHYSIOLOGY  OF  PURE,VESTIBULAR  NYSTAGMUS  PRODUCED 
BY    ROTATION. 

When  the  head  is  erect  and  the  subject  turned  around  the  vertical 
axis  with  the  eyes  closed,  there  is  a  horizontal  nystagmus  in  the  direc- 
tion of  turning  which  may  be  felt  thru  the  closed  lids ;  the  rapidity  of 
this  nystagmus  is  in  proportion  to  the  rapidity  of  the  turning.  If  the 
turning  is  continued  long  enough,  however,  the  nystagmus  ceases.  The 
nystagmus  thus  produced  is  known  as  turning  vestibular  nystagmus. 

If  after  more  or  less  turning  the  subject  is  brought  to  a  standstill,  he 
exhibits  an  after-turning  nystagmus  directed  to  the  opposite  side  to 
v:hich  the  turnings  had  been  made;  this  is  designated  as  an  after- 
nystagmus  (a  term  meaning  the  same  and  contracted  from  the  more 
compound  term  of  after-turning  nystagmus).  The  explanation  for 
turning  and  after-turning  nystagmus  offered  by  Breuer  and  generally 
accepted,  is  that  of  endolymph  pressure  against  the  cupola  of  the  crista 


LABYRINTH  PAPERS.  133 

ampullaris  which  causes  an  inclination  of  the  cilia,  which  in  turn  pro- 
duces the  sensation  of  turning  and  the  reflex  nystagmus.  For  instance, 
in  the  case  of  turning  with  the  head  erect :  at  the  beginning  of  turning, 
say  to  the  right,  the  endolymph  in  the  horizontal  canals  lags  behind 
because  of  inertia,  just  as  one  standing  in  a  car  tends  to  fall  backward 
when  the  car  starts  forward.  This  results  in  a  relative  movement  of 
the  endolymph  in  the  horizontal  canals  in  the  opposite  direction  (to 
the  left),  which  is  equivalent  to  a  movement  of  the  endolymph  in  the 
right  horizontal  canal  toward  the  ampulla  with  a  corresponding  in- 
clination of  the  cilia  toward  the  utriculus,  and  a  movement  of  the  endo- 
lymph in  the  left  horizontal  canal  toward  the  nonampullar  end  with  an 
inclination  of  the  cilia  away  from  the  utriculus. 

In  both  cases — endolymph  pressure  in  the  righ^  canal  toward  the 
ampullar  end  and  in  the  left  canal  away  from  the  ampullar  end — 
nystagmus  to  the  right  is  produced.  These  results  correspond  exactly 
with  the  results  obtained  by  Ewald  who  produced  mechanically  these 
same  endolymph  pressures  toward  and  away  from  the  ampulla. 

Thus  we  see  that  no  matte-  how  it  may  be  produced  endolymph 
motion  in  the  horizontal  canal  toward  the  ampullar  end  causes  hori- 
zontal nystagmus  to  the  same  side,  A\~*  •  .i^lymph  motion  away  from 
the  ampullar,  i.  c.,  toward  the  nom>  npullar  end  causes  horizontal 
ny-tagmus  to  the  opposite  side.  See  illustration,  No.  X. 

This  movement  of  the  endolymph  in  the  opposite  direction  to  the 
movement  of  the  canal  continues  only  so  long  as  there  is  a  c  c  e  1  e  r  a- 
t  i  o  n  of  the  turning  motion.  Let  the  turnings  become  of  uniform 
velocity  the'n  the  endolymph  will  sooner  or  later  acquire  the  same  veloc- 
ity as  the  canals  themselves  when  there  will  cease  to  be  any  relative 
movement  of  the  endolymph  in  the  canals.  At  this  moment  the  cilia  ac- 
cording to  Breuer  and  Barany  begin  to  re-establish  their  normal  posi- 
tion of  rest — that  is  a  position  vertical  to  their  insertion  base.  This  re- 
establishment  to  the  primary  position  is  brought  about  by  the  elasticity 
of  the  cilia  and  of  the  gelatinous  substance  which  holds  them  together. 
This  assumption  of  Breuer,  supported  by  Barany,  is  based  upon  the 
fact  that  after  turning  has  been  continued  uniformly  for  some  length 
of  time,  the  physiological  reflex  (nystagmus)  ceases. 

After-turning  nystagmus,  according  to  the  same  authority,  is  ex- 
plained as  follows: 

Taking  the  same  case  (subject  turning  to  the  right  with  head  erect), 
at  the  moment  of  cessation  of  turning  the  canals  cease  also,  but  not  so 


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FIG.  3 


LABYRIXTH  PAPERS.  135 


Illustration  X.  Fig.  I  illustrates  the  quiescent  state  of  the  endolymph  in  the 
horizontal  semicircular  canals.  E.  C.  L.  H.  represents  the  external  crus  of  the 
left  horizontal  canal;  E.  C.  R.  H.  the  external  crus  of  the  right  horizontal  canal; 
C.  A.  the  crista  ampullaris ;  C.  C.  A.  the  cilia  of  the  crista  ampullaris  in  a  state 
of  rest  perpendicular  to  the  base.  L.  U.  relative  position  of  the  left  utriculus; 
R.  U.  right  utriculus ;  L.  E.  left  eye,  and  R.  E.  right  eye ;  both  eyes  looking 
straight  ahead. 

Fig.  2  illustrates  the  influence  of  rotation  of  the  head  to  the  left :  (a)  Upon  the 
cilia  of  the  crista  ampullaris  in  both  right  and  left  horizontal  canals,  and  (b) 
upon  the  eyes  to  produce  turning — nystagmus  to  the  left. 

The  large  arrow  L.  R.  represents  left  rotation  of  the  head.  The  arrow  E.  M. 
L.  H.  the  direction  of  endolymph  motion  in  the  left  horizontal  canal,  toward  the 
ampulla  producing  an  inclination  of  the  cilia  toward  the  left  utriculus  (L.  U.). 
The  arrow  E.  M.  R.  H.  represents  the  direction  of  the  endolymph  motion  in  the 
right  horizontal  canal  away  from  the  ampulla,  causing  an  inclination  of  the  cilia 
away  from  the  right  utriculus  (R.  U.).  The  straight  arrow  N.  L.  represents  the 
direction  of  the  nystagmus  to  the  left,  produced  by  the  inclination  of  the  cilia  in 
either  or  both  canals. 

Fig.  3  illustrates  the  influence  of  cessation  of  head  rotation  to  the  left:  (a) 
Upon  the  cilia  of  the  crista  ampullaris  in  both  right  and  left  horizontal  semi- 
circular canals,  (b)  upon  the  eyes  to  produce  after-turning  nystagmus  to  the 
right.  The  arrow  E.  M.  L.  H.  the  direction  of  endolymph  motion  in  the  left 
horizontal  canal  away  from  the  ampulla,  producing  inclination  of  the  cilia  away 
from  the  left  utriculus  (L.  U.).  The  arrow  E.  M.  R.  H.  the  direction  of  the 
endolymph  motion  in  the  right  horizontal  canal  toward  the  ampulla,  producing 
inclination  of  the  cilia  toward  the  right  utriculus  (R.  U.).  The  straight  arrow 
N.  R.  represents  the  direction  of  the  nystagmus  to  the  right  produced  by  the 
inclination  of  the  cilia  in  either  or  both  canals. 


i36  TURNING  AND  AFTER-TURNING  NYSTAGMUS. 

the  endolymph,  which  continues  to  move  in  the  same  direction,  just  as 
onp  standing  in  the  car  tends  to  move  forward  for  a  moment  after  the 
car  comes  to  a  stop.  In  consequence  there  is  a  relative  movement  of 
the  endolymph  in  the  right  horizontal  canal  from  the  ampullar  towrard 
the  nonampullar  end  and  with  it  a  corresponding  motion  of  the  cupula 
together  with  inclination  of  the  cilia  a^'ay  from  the  utriculus :  and  in 
the  left  horizontal  canal  a  movement  of  the  endolymph  from  the  non- 
ampullar toward  the  ampullar  end,  with  a  corresponding  motion  of  the 
cupula  and  inclination  of  the  cilia  toward  the  utriculus ;  both  of  which 
produce  an  after-turning  nystagmus  to  the  left  (in  the  direction  contrary 
to  the  turning.)  The  rapidity  of  the  after-turning  nystagmus  is  more 
or  less  in  proportion  to  the  rapidity  of  turning  which  precedes  it ;  how- 
ever, the  duration  does  not  vary  appreciably  one  way  or  the  other. 

When  the  head  is  held  in  such  a  position  that  rotation  occurs  exactly 
in  the  plane  of  the  horizontal  canals,  the  maximum  amount  of  endo- 
lymph motion  occurs  in  these  canals  (both  during  a  nd  after  rotation)  ; 
in  which  case  we  have  the  most  pronounced  and  the  purest  form  of 
horizontal  nystagmus.  When  the  head  is  inclined  away  from  this 
plane  the  amount  of  endolymph  motion  in  these  canals  diminishes  pro- 
portionately, while  at  the  same  time  the  endolymph  motion  begins  to 
occur  in  the  remaining  canals  and  proportionately  to  the  inclination. 
As  a  result,  the  nystagmus  begins  to  lose  its  horizontal  and  assumes 
another  character.  If  the  head  is  inclined  90°  forward  or  backward,  so 
that  the  plane  of  the  horizontal  canals  is  at  right  angles  to  the  plane  of 
rotation,  then  no  endolymph  motion  in  the  horizontal  canals  can  occur. 
but  instead  endolymph  motion  in  the  two  vertical  canals  of  each  side 
resulting  in  the  purest  form  of  rotatory  nystagmus.  The  rotatory 
nystagmus  has  occurred  as  a  result  of  the  irritation  of  four  vertical 
canals,  two  on  each  side. 

Altho  Ewald,  by  careful  research  with  his  pneumatic  hammer,  had 
determined  positively  the  effects  of  endolymph  motions  (both  toward 
and  away  from  the  ampulla)  in  the  case  of  each  of  the  canals  it  be- 
comes quite  a  mathematic  problem  to  figure  out  accurately  in  which 
canals  the  endolymph  movement  .occurs  and  the  direction  it  oc- 
curs in  the  case  of  turning  in  the  various  planes  (frontal,  saggital. 
oblique,  etc.).  Fortunately,  for  practical  purposes  alone,  it  is  not  neces- 
sary to  resort  to  mathematics,  since  we  have  other  definite  and  much 
simpler  laws,  to  guide  us  as  to  the  plane  and  direction  in  which  a 
nvstagmus  should  occur  from  turning.  They  are : 


LABYRINTH  PAPERS.  137 

I.  Turning  nystagmus  occurs  in  the  plane  of  rotation  of  the  head. 

II.  The  direction  of  turning  nystagmus  is  in  the  direction  of  rota- 
tion of  the  head. 

III.  The  plane  of  the  after-nystagmus  is  the  same  as  that  of  the 
turning  nystagmus. 

IV.  The  direction  of  the  after-turning  nystagmus  is  opposite  to  that 
of  the  turning  nystagmus. 

ILLUSTRATIONS. 

I.  As  previously  stated,  if  the  head  is  held  erect,  so  that  the  hori- 
zontal canals  lie  approximately  in  the  horizontal  plane  and  the  subject  is 
turned  about  the  vertical  axis  to  the  right  (as  the  hands  of  a  watch 
move)  a  rhythmic  horizontal  nystagmus  to  the  right  occurs  during  the 
turning  and  a  rhythmic  horizontal  nystagmus  to  the  left  occurs  after 
cessation  of  turning. 

II.  If  the  head  is  inclined  90°  forward  so  that  a  plane  thru  the 
corneal  limbus  lies  in  the  horizontal  plane  and  the  subject  is  turned 
about  the  vertical  axis  to  the  right,  a  rhythmic  rotatory  nystagmus  to 
the  right  occurs  during  turning  to  the  right  and  a  rhythmic  rotatory 
nystagmus  to  the  left  occurs  after,  cessation. 

III.  If  the  head  is  inclined  90°  backward  so  that  a  plane  thru  the 
corneal  limbus  lies  in  the  horizontal  plane  and  the  subject  is  turned 
to  the  right,  a  rotatory  nystagmus  to  the  left  is  produced  during  the 
turning  and  to  the  right  after  cessation. 

IV.  If  the  head  is  inclined  90°  to  the  right  so  that  the  vertical 
meridians  of  the  eyes  lie  in  the  horizontal  plane  and  the  subject  is 
turned  to  the  right,  a  vertical  nystagmus  upward  occurs  during  the 
turning  and  downward  after  turning. 

Y.  If  the  head  is  inclined  45°  forward  (a  position  midway  between 
horizontal  and  that  of  90°  forward)  and  the  subject  is  turned  to  the 
right,  a  combination  of  horizontal  and  rotatory  nystagmus  to  the  right 
occurs  during  turning  and  to  the  left  after  turning. 

VI.  If  the  head  is  inclined  45°  backward  (a  position  midway  be- 
tween the  horizontal  and  that  of  90°  backward)  and  the  subject  is  turn- 
ed to  the  right,  a  combination  of  horizontal  nystagmus  to  the  right  with 
rotatory  nystagmus  to  the  left  occurs  during  the  turning  and  a  hori- 
zontal nystagmus  to  the  left  combined  with  rotatory  nystagmus  to  the 
right  after  turning. 

YII.     If  the  head  is  inclined  45°  to  the  right  and  the  subject  is 


138  TURXIXG  AXD  AFTER-TURXfXG  XVSTAG.MUS. 

turned  to  the  right,  an  oblique  nystagmus  upward  and  to  the  right  oc- 
curs during  turning  and  an  oblique  nystagmus  downward  and  to  the 
left  after  turning. 

From  these  seven  illustrations  it  is  an  easy  matter  to  reason  out 
others.  All  of  these  forms  of  nystagmus  are  increased  in  intensity  when 
looking  to  the  side  toward  the  direction  of  the  nystagmus  and  diminish- 
ed when  looking  to  the  opposite  side.  Following  the  same  law,  the  case 
of  illustration  VI  (head  inclined  backward  45°),  resulting  in  after- 
nystagmus  of  combined  horizontal  to  the  left  with  rotatory  to  the  right 
— the  horizontal  character  is  more  pronounced  when  looking  to  the  left 
and  the  rotatory  character  more  pronounced  when  looking  to  the  right. 

Vestibular  nystagmus  is  accompanied  by  other  phenomena,  both  sub- 
jective and  objective,  which  may  be  studied  more  accurately  and  to  the 
best  advantage  when  it  has  been  produced  by  the  turning  method 
These  are : 

I.     Visual    sensations. 

II.     Subjective    sensation    of    mo  ti  o  n  (turning,  fall- 
ing, etc.). 

III.     Reaction   movements.     (Equilibrium  disturbance.) 

The  first  and  second  of  these  may  be  considered  likewise  the  sub- 
jective sensations  of  vestibular  vertigo. 

Let  us  take  the  case  (in  which  by  turning  to  the  left  with  head 
inclined  forward  90°)  a  rotatory  after-nystagmus  to  the  right  has 
been  produced.  The  rotatory  after-nystagmus  to  the  right  remains  as 
such  so  long  as  the  reaction  lasts,  no  matter  to  which  position  the  head 
may  be  changed ;  however,  a  change  of  position  of  the  head  will  change 
relatively  the  plane  and  direction  the  nystagmus  makes  to  the  erect 
body  and  to  the  external  world. 

For  instance,  so  long  as  the  head  is  allowed  to  remain  in  the  primary 
position,  i.  e.,  head  inclined  90°  forward  to  the  erect  body,  so  that  the 
face  looks  toward  the  floor,  the  rotatory  after-nystagmus  to  the  right  is 
occurring  in  the  horizontal  plane  and  is  directed  to  the  right.  The 
quick  movements  of  the  eyes  occur  in  the  same  plane  and  direction  as 
move  the  hands  of  a  watch  lying  upon  a  table  with  the  face  up.  The 
nystagmus  is  taking  place,  in  relation  to  the  head,  in  the  frontal  plane : 
but  in  relation  to  the  erect  body  and  also  to  the  external  world  in  the 
horizontal  plane. 

If  the  head  of  the  subject,  who  remains  sitting  or  standing 
vertically  erect,  is  shifted  to  the  erect  position  so  that  the  face  is 


LABYRINTH  PAPERS.  139 

directed  straight  ahead,  the  rotatory  after-nystagmus  to  the  right  will 
be  found  to  remain  unchanged  in  relation  to  the  head  (frontal  plane), 
but  in  the  relation  to  the  body  and  to  the  external  world  it  will  have 
changed  from  the  horizontal  (as  in  the  former  instance)  to  the  frontal. 

If  during  the  reaction  the  head  is  turned  90°  to  the  right  so  that  the 
eyes  are  directed  horizontally  over  the  right  shoulder,  the  rotatory 
after-nystagmus  to  the  right  must  occur  in  the  sagittal  plane  of  the 
body  while  the  quick  movement  of  the  eyes  will  be  directed  backward. 
If  during  the  reaction  the  head  is  turned  90°  to  the  left  so  that  the 
eyes  are  directed  horizontally  over  the  left  shoulder,  then  the  rotatory 
after-nystagmus  to  the  right  must  occur  in  the  sagittal  plane  of  the 
body  while  the  quick  movements  of  the  eyes  will  be  directed  forward. 

If  during  the  reaction,  the  erect  head  is  turned  90°  backward  so  that 
the  face  is  directed  towards  the  zenith,  then  the  rotatory  after-nystag- 
mus to  the  right  occurs  in  the  horizontal  plane  and  the  quick  move- 
ments are  directed  to  the  left  (the  same  plane  and  direction  as  the 
hands  of  a  watch  move  when  its  face  is  turned  downward  upon  the 
table  or  the  reverse  of  that  which  is  made  when  the  face  of  the  subject 
is  directed,  downward,  toward  the  floor). 

From  the  foregoing  certain  facts  have  been  brought  out  which  are 
common  to  every  after-turning  nystagmus  and  may  be  briefly  stated  as : 

(a)  The  plane  and  direction  of  after-turning  nystagmus  retains  its 
same  plane  and  direction  relatively  to  the  head  as  long  as  the  reaction 
lasts,  no  matter  how  the  position  of  the  head  may  be  changed. 

(b)  The    plane    and    direction    of    the    after-turning    nystagmus 
changes  its  plane  and  direction  relatively  to  the  body  and  to  the  ex- 
ternal surroundings  with  every  change  of  position  of  the  head. 

These  facts  must  be  reckoned  wdth  also  in  considering  the  three  as- 
sociated phenomena  of  vestibular  nystagmus.  It  will  be  found  that 
change  of  position  of  the  head  influences  not  only  the  plane  and  direc- 
tion of  the  nystagmus  in  relation  to  the  body  and  the  external  world, 
as  already  pointed  out,  but  also  the  visual  sensations,  the  subjective 
.ensation  of  motion  and  the  objective  (reaction  movements)  equilib- 
rium disturbance. 

I.      VISUAL    SENSATIONS. 

The  visual  sensations  accompanying  vestibular  nystagmus  are  ex- 
pressed variously  by  different  individuals.  For  instance  in  the  case  of 
rotatory  nystagmus  to  the  right,  we  may  by  inquiry  elicit  the  following 
expressions : 


I4o  TURNING  AND  AFTER-TURNING  NYSTAGMUS. 

(a)  The  (visual)  sensation  of  objects,  rolling  continuously  to  the 
right,  i.  c .,  the  outer  world  appears  to  be  rotating  about  the  visual  axis 
to  the  right. 

(b)  The  sensation  of  external  objects  rolling  to  the  right  with 
periods  of  brief  interruptions  which  find  the  objects  back  to  their 
primary  (normal)  position  from  which  they  repeat  the  rolling. 

(c)  The  sensation  of  seeing  the  external  world  or  room  double; 
one  stationary  and  in  normal  position  while  the  second  appears  to  be 
rolling  to  the  right. 

(d)  Some  few  subjects  perceive  no  motion  at  all  but  simply  see 
objects  double. 

(e)  Of  those  who  experience  the  sensation  of  external  objects  mov- 
ing to  the  left,  the  writer  doubts  the  accuracy  of  their  observations. 

The  sensation  of  objects  rolling  to  the  right,  either  continuously  or, 
more  accurately,  interruptedly — as  experienced  by  the  vast  majority  of 
people  during  rotatory  nystagmus  to  the  right — is  the  normal  sensation 
and  can  be  easily  explained.  For  instance,  an  involuntary  movement  of 
the  eyeballs  to  one  side  is  interpreted  as  the  sensation  of  motion  of  ex- 
ternal objects  to  the  opposite  side;  objects  to  the  left  are  perceived 
upon  the  retina  to  the  right  of  the  macula,  and  conversely  every  retinal 
impression  which  falls  upon  the  left  side  of  the  macula  is  projected  to 
the  right  and  perceived  as  an  object  upon  the  right 

In  the  case  of  very  active  nystagmus  of  long  excursions,  the  quick 
movements  may  occur  so  quickly  that  retinal  impressions  are  barely 
possible,  but  interruptions  take  place.  The  quick  excursion,  however, 
has  brought  the  eyes  back  to  their  primary  (normal)  position  from 
whence  the  slow  movement  begins  to  repeat  itself  and  with  it  comes  a 
repetition  of  the  sensation  of  external  objects  rolling. 

Since  retinal  impressions  are  liable  to  take  place  during  the  slow 
excursion  only,  then  it  must  follow  according  to  the  law  of  projection 
that  external  objects  are  perceived  by  the  subject  as  moving  in  the 
direction  contrary  to  the  slow  excursion,  in  other  words,  in  the  same 
direction  as  the  nystagmus.  For  illustration  see  Fig.  2. 

In  those  cases  where  the  subjects  express  themselves  with  having 
seen  two  rooms,  one  stationary  and  the  other  rolling,  the  sensations 
may  be  explained  as  follows:  that  seen  as  the  stationary  room  in  its 
normal  position  and  relation  is  due  to  the  rapid  succession  of  retinal 
impressions  obtained  at  the  moment  the  eyes  have  leaped  back  to  their 
primary  position  (Einstellung),  which  impressions  linger  sufficiently 


LABYRINTH  PAPERS,  MI 

long  to  produce,  by  their  very  rapidity,  quite  a  continuous  visual  sensa- 
tion.  The  other  or  second  impression,  that  of  the  rolling  room,  has 
already  been  explained. 

In  the  cases  where  the  subjects  experienced  diplopia  without  the 
sensation  of  objects  rolling  was  due,  in  the  one  case  seen  by  the 
writer,  to  an  actual  convergent  strabismus  which  lasted  as  long  as  the 
average  after-nystagmus  lasts.  The  eye  of  the  side  to  which  the  after- 


FIG.  2. — E  represents  the  eyeball  at  rest  just  before  the  slow  excursion  begins. 
Object  O  produces  a  visual  image  at  the  macula  M  and  the  object  is  perceived 
in  its  normal  position.  E'  represents  the  position  of  the  eyeball  at  the  end  of  the 
slow  excursion  to  the  left,  as  indicated  by  the  arrow  L,  the  image  of  object  O 
upon  the  retina  has  moved  to  the  left,  as  indicated  by  the  arrow  A  to  point  I. 
Since  retinal  impressions  at  I  (to  the  left  of  the  macula)  are  referred  to  the 
right  then  the  object  O  has  apparently  moved  to  the  right,  as  indicated  by  the 
arrow  R,  to  the  point  O'. 

nystagmus  should  occur  was  deviated  inward.  This  patient  therefore 
manifested  the  vestibular  reflex  (slow  movement)  only  and  that  of  the 
one  eye.  The  subject  having  been  unable  to  voluntarily  bring  the  eye 
back  to  its  primary  position  (Einstellung)  until  after  the  reflex  had 
passed. 

Just  as  in  the  case  of  nystagmus  so  in  the  case  of  visual  sensations 


i4-'  TL'RMXG  A\D  AFTER-TURNING  NYSTAGMUS. 

of  external  objects  rolling,  etc.,  the  intensity  is  increased  when  looking 
toward  the  side  to  which  the  nystagmus  is  directed  and  diminished 
when  looking  toward  the  opposite  side. 

Change  of  position  of  the  head  will  change  the  plane  and  direction 
of  apparent  turning.  Citation  of  a  single  case  will  be  sufficient  to 
illustrate  the  point. 

For  instance,  in  the  case  of  horizontal  after-nystagmus  to  the  right 
so  long  as  the  patient  holds  the  head  erect  he  experiences  the  sensation 
of  surrounding  objects  rotating  in  the  horizontal  plane  to  the  right. 
If  the  position  of  the  head  is  so  changed  that  it  is  inclined  90°  to  the 
right,  i.  e.,  the  right  side  of  the  face  resting  upon  the  right  shoulder 
with  face  directed  forward,  the  horizontal  nystagmus  will  then  occur 
in  the  vertical  sagittal  plane  of  the  body  and  the  quick  movement  will 
be  directed  downward ;  the  visual  sensation  must  therefore  be  that  of 
objects  falling  vertically  downward  toward  the  floor. 

II.    SUBJECTIVE  SENSATION  OF  MOTION. 

The  subject  with  an  after-nystagmus  experiences  a  sensation  of 
motion  in  the  plane  and  direction  of  his  nystagmus  which  is  increased 
when  looking  in  the  direction  of  the  nystagmus  and  diminished  when 
looking  in  the  opposite  direction.  For  instance,  a  patient  with  hori- 
zontal nystagmus  to  the  right  experiences  a  sensation  of  turning  or 
rotation  to  the  right.  In  case  of  rotatory  nystagmus  to  the  right  the 
plane  of  the  nystagmus  is  frontal,  hence  he  suffers  the  sensation  of 
falling  laterally  to  the  right.  In  the  case  of  vertical  nystagmus  down- 
ward, the  plane  of  the  nystagmus  is  sagittal,  hence  the  patient  has  the 
sensation  of  falling  forward. 

These  sensations  are  not  entirely  dependent  upon  the  visual  im- 
pressions, for  they  are  present  with  the  eyes  closed  as  well  as  with  the 
eyes  open.  Again  the  subjective  sensation  of  motion  endures  as  long 
as  the  after-nystagmus,  and  is  felt  by  the  subject  whether  he  is  stand- 
ing, sitting  or  lying  down. 

The  sensation  of  turning  or  falling  when  the  eyes  are  open  is  de- 
pendent mostly  upon  the  visual  impressions — that  of  objects  turning  or 
tumbling.  As  the  room  in  which  one  is  standing  seems  to  turn  in  a 
given  direction  the  subject  will  naturally  feel  as  tho  he  is  going  with 
it.  This  same  sensation  of  turning  or  tumbling  is  experienced  by  one 
with  rhythmic  nystagmus  even  when  produced  optically,  as  by  Mach's 
rotating  cylinder  experiments,  in  the  muscle  paresis,  etc.  Visual  im- 


LABYRINTH  PAPERS.  143 

pressions  however  do  not  explain  the  sensation  of  turning  or  falling 
experienced  in  vestibular  nystagmus  with  the  eyes  closed. 

Barany  (Phys.  u.  Path,  des  Bogeng.)  who  has  studied  the  subject 
most  carefully  is  undecided  as  to  whether  the  falling  sensation  is  due  to 
an  irritation  conveyed  directly  to  the  cortex  thru  vestibular  fibers,  or 
whether  the  sensation  arises  thru  the  medium  of  the  nystagmus.  Ac- 
cording to  Ewald  (Physiolog.  Untersuchungen  ueber  das  Endorgan 
des  N.  Octavus),  we  are  led  to  believe  that  the  sensation  of  falling  is 
due  to  an  overbalance  of  muscle  innervation  of  one  side  of  the  body 
produced  by  the  vestibular  reflex. 

There  are  certain  facts  which  contradict  the  theory  that  these  sensa- 
tions are  the  result  of  impulses  which  are  conveyed  to  the  cortex. 
Flourens  (Comptes  Rendus,  Tome  LII,  p.  673-75)  and  others  have 
found  that  animals  whose  cerebral  hemispheres  have  been  removed 
show  the  same  reactions  as  before.  Again,  if  cortical  perception  was 
entirely  responsible  for  the  falling  sensations  then  the  sensations  should 
remain  constantly  the  same  in  spite  of  change  of  position  of  the  head, 
which  is  contrary  to  the  facts  as  we  find  them. 

For  similar  reason  we  must  deny  Ewald's  explanation  of  muscle 
tonus. 

If  the  muscular  hyper-  and  hypotonus  theory  was  correct  then 
movements  of  the  head  should  not  influence  the  plane  or  direction 
which  the  sensation  of  turning  or  falling  takes,  or  that  of  the  actual 
reaction  falling. 

For  instance,  a  patient  manifesting  a  rotatory  nystagmus  to  the  right 
because  of  destruction  of  the  left  semicircular  canals  or  stimulation 
of  the  right  semicircular  canals,  the  hypertonus  of  one  side  and  hypo- 
tonus of  the  opposite  side  should  remain  constantly  the  same  in  spite 
of  any  change  of  position  of  the  head  ;  the  subject  should  fall  constantly 
to  the  one  side.  The  fact  however  is  that  both  the  sensation  and  the 
reaction  falling  may  be  reversed  in  their  directions  by  a  change  of 
position  of  the  head  of  180°. 

From  the  facts  as  we  find  them  it  would  seem  that  one  explanation 
alone  is  left  us,  and  that  is:  The  sensation  of  falling  and  the  objective 
falling  is  dependent  not  upon  the  cerebral  hemispheres,  but  upon  the 
cerebellum. 

The  writer  would  attempt  the  following  explanation :  That  the  reflex 
slow  movement  of  the  eyes  to  the  left  in  case  of  stimulation  of  the 
right  semicircular  canals  occurs  independently  of  the  great  brain,  as 


144  TURXIXG  AXD  AFTER-TURXIXG  XYSTAGMUS. 

shown  by  Flourens's  experiments.  Furthermore,  since  we  have  come  to 
accept  the  cerebellum  as  the  central  organ  for  the  control  of  equi- 
librium and  that  the  kinesthetic  sense  impulses  are  conveyed  to  the 
cerebellum  from  the  deep  muscles,  joints,  etc.,  from  all  parts  of  the 
body,  may  we  not  look  upon  the  reflex  contraction  of  certain  eye 
muscles  as  producing  similar  kinesthetic  sense  impulses  which  are  con- 
veyed likewise  to  the  cerebellum?  In  brief,  the  opinion  of  the  writer  is 
that  when  by  stimulation  of  the  right  horizontal  semicircular  canal 
the  eyes  deviate  to  the  left,  the  involuntary  reflex  contraction  of  the  left 
abductor  and  the  right  adductor  causes  a  kinesthetic  sensation  of  con- 
traction of  these  muscles  which  is  conveyed  to  the  cerebellum  in  the 
same  manner  as  all  other  kinesthetic  sensations  are,  and  is  interpreted 
in  the  cerebellum  as  the  sensation  of  torsion  of  the  body  to  the  right 
which  the  cerebellum  as  the  central  organ  for  equilibrium  attempts  to 
correct  by  sending  motor  impulses  to  certain  body  muscles  to  produce 
the  opposite  torsion.  However,  since  the  sensation  of  torsion  is  only 
apparent  and  not  real,  the  attempt  to  unwind  the  apparent  body  tor- 
sion produces  an  actual  torsion  in  the  opposite  direction. 

III.       REACTION    MOVEMENTS    (EQUILIBRIUM    DISTURBANCE). 

The  subject  with  an  after-nystagmus  will  move  or  fall  in  the  plane 
of  his  nystagmus  but  in  the  contrary  direction.  For  instance,  a  subject 
with  horizontal  nystagmus  to  the  right  will  tend  to  turn  in  the  hori- 
zontal plane,  that  is  make  a  torsion  movement  of  the  head  and  body  to 
the  left.  In  the  case  of  rotatory  nystagmus  to  the  right  the  plane  of 
the  nystagmus  is  frontal,  hence  the  subject  will  tend  to  fall  laterally 
to  the  left.  In  the  case  of  vertical  nystagmus  downward  the  plane  of 
the  nystagmus  is  vertical  and  the  direction  is  downward,  hence  the  sub- 
ject will  tend  to  fall  vertically  backward. 

As  pointed  out  elsewhere  the  plane  and  direction  of  an  after-turning 
nystagmus  remain  the  same,  no  matter  how  we  may  change  the  posi- 
tion of  the  head.  A  rotatory  after-turning  nystagmus  to  the  right  re- 
mains as  such  whether  the  head  is  kept  forward,  turned  upward,  back- 
ward or  to  either  side;  however,  with  a  change  of  the  head  position 
comes  a  change  in  the  plane  and  direction  of  the  falling  sensation  and 
of  the  actual  falling. 

A  few  cases  may  be  cited  to  illustrate  this  point.  For  instance,  in 
case  of  rotatory  nystagmus  to  the  right  the  subject  has  the  subjective 
sensation  of  falling  laterally  to  the  right,  because  of  which  in  his  at- 


LABYRINTH  PAPERS.  145 

tempt  to  correct  he  really  over  corrects  and  actually  falls  laterally  to 
the  left.  Xow  if  the  subject's  head  is  turned  90°  to  the  left  so  that  the 
face  is  directed  to  the  left,  his  rotatory  nystagmus  to  the  right  con- 
tinues as  such,  but  it  occurs  in  the  sagittal  plane  of  his  body.  As  a  re- 
sult the  subject  experiences  the  subjective  sensation  of  falling  forward, 
which  his  attempt  to  correct  causes  him  to  fall  backward.  If  the 
head  should  be  turned  90°  to  the  right,  so  that  the  subject  is  looking 
horizontally  to  the  right,  the  rotatory  nystagmus  is  taking  place  in  the 
sagittal  plane  and  directed  backward  and  downward,  in  which  case  the 
subject  experiences  the  false  subjective  sensation  of  falling  backward, 
which  in  his  attempt  to  correct  causes  him  to  fall  forward.  If  the  head 
should  be  inclined  forward  90°  so  that  the  subject  looks  down- 
ward, toward  the  floor,  the  rotatory  nystagmus  to  the  right  occvrs  in 
the  horizontal  plane;  the  subject  experiences  the  false  sensation  of 
torsion  to  the  right,  which  in  his  attempt  to  correct  he  actually  tvrns 
around  the  vertical  axis  of  his  body  (in  the  horizontal  plane)  to  the 
left.  In  the  case  of  horizontal  nystagmus  to  the  right  with  the  head 
upright  the  subject  naturally  suffers  the  sensation  of  turning  in  the  hori- 
zontal plane  to  the  right,  but  actually  turns  to  the  left.  If  the  lie-ul  is 
inclined  90°  forward  so  that  the  patient  is  looking  toward  the  floor  the 
horizontal  nystagmus  remains  as  such,  but  the  nystagmus  occurs 
in  the  frontal  plane  of  the  body,  which  is  equivalent  to  a  rotatory 
nystagmus  to  the  left  with  head  erect,  the  corresponding  false  sen..a- 
tion  is  that  of  falling  to  the  left,  which  causes  the  patient  to  actually 
fall  to  the  right.  If  the  head  is  inclined  90°  backward  so  that  the  sub- 
ject look?  toward  the  zenith,  the  horizontal  nystagmus  remains  the 
same,  but  the  nystagmus  occurs  in  the  frontal  plane  of  the  body, 
equivalent  to  a  rotatory  nystagmus  to  the  right  with  the  head  erect.  !TI 
which  case  the  patient  experiences  the  false  sensation  of  falling  tc  the 
right,  which  results  in  the  subject  actually  falling  to  the  left.  So  we 
might  continue  the  number  of  illustrations. 

Barany  teaches  (Phys.  u.  Path,  des  Bogeng.  Appar.  beim  Menscht'u. 
page,  14,  third  paragraph  from  the  bottom)  that  the  sensation  of  fall- 
ing is  increased  when  the  eyes  are  closed.  This  is  probably  so,  for  we 
find  the  subject  has  a  greater  tendency  to  fall  with  the  eyes  closed  than 
when  open. 

Beside  the  above  typical  phenomena  which  are  constantly  present  in 
association  with  vestibular  nystagmus,  we  find  other  symptoms  more 
or  less  present.    These  are : 
10 


146  ,  TL'RXIXG  AXD  AFTER-TURXIXG  XYSTAGML'S. 

IV.  Nausea  and  vomiting,  which  occur  most  constantly  in  connec- 
tion with  the  rotatory  form  of  nystagmus  and  least  constantly  in  con- 
nection with  the  horizontal. 

V.  Vasomotor  changes.     Flushing  and  pallor  of  the  face,  profuse 
sweating,  etc. 

VI.  Nervous  and  hysterical  phenomena  and  epileptiform  attacks 
are  not  uncommon  in  those  so  inclined. 

METHOD  OF  MAKING  THE  EXAMINATION. 

As  a  result  of  his  thoro  and  painstaking  experiments,  Barany  has  de- 
veloped an  accurate  method  for  the  determination  of  the  reactions  of 
the  semicircular  canals  to  turning.  At  the  same  time  he  has  supplied 
us  with  data  and  figures  of  inestimable  value  in  the  differentiation  of 
the  normal  from  the  abnormal. 

Before  Barany  began  his  researches,  the  best  apparatus  for  the  study 
of  turning  nystagmus  was  a  large  revolving  platform  upon  which  sat 
or  stood  both  the  subject  and  the  experimenter.  This  apparatus  was 
Cumbersome  and  costly.  At  that  time  the  experimenters  studied  mostly 
the  reactions  (nystagmus)  during  the  turnings. 

Later,  as  Barany  found  the  reactions  after  turning  were  just  as 
positive  and  even  more  accurate  than  during  turning,  he  dis- 
carded the  revolving  platform,  and  used  the  less  expensive  and  more 
available  revolving  stool,  so  that  today  the  method  as  developed  by 
Barany  can  be  practiced  by  any  one  in  his  office  and  without  the  aid  of 
an  assistant. 

To  make  the  examination,  one  needs  a  suitable  revolving  stool  fitted 
•with  a  bearing  that  does  not  permit  elevation  or  depression  when 
turning,  and  a  metal  or  wooden  bar  fastened  to  the  back  and  reaching 
above  the  patient's  head  to  serve  as  a  handle.  An  illustration  of  the 
one  used  by  the  writer  may  be  seen  in  the  paper  upon  "Labyrinth 
Suppuration — Two  Cases."  Besides  this,  one  needs  a  stop  watch  and 
a  pair  of  opaque  spectacles.  The  spectacles  used  by  the  writer  are 
nothing  more  than  a  pair  of  dark  glasses  with  adhesive  plaster  fast- 
ened to  the  external  surface. 

The  subject  should  be  seated  comfortably  in  the  revolving  stool  with 
the  feet  just  escaping  the  floor.  It  is  well  to  have  handles  on  the  chair 
that  the  patient  may  hold  on  well  and  avoid  toppling  over.  The  ex- 
aminer stands  in  front  of  the  chair  with  his  feet  and  legs  far  enough 
from  those  of  the  subject  to  avoid  collision.  In  one  hand  is  held  the 


LABYRINTH  PAPERS.  147 

stop  watch,  with  the  other  hand  reaching  over  the  subject's  head  the 
top  of  the  handle  is  grasped.  The  patient  is  instructed  to  hold  fast  for 
fear  of  losing  his  balance.  The  turnings  should  be  made  as  nearly  uni- 
form as  possible,  consuming  about  two  seconds  for  a  complete  turn 
(360  degrees).  Turning  ten  times  (3,600  degrees)  as  a  rule  produces 
the  maximum  amount  and  duration  of  after-nystagmus,  as  determined 
by  Barany  and  corroborated  by  others.  When  one  wishes  to  examine 
for  horizontal  after-nystagmus  to  the  right,  naturally  we  must  turn  the 
subject  to  the  left,  i.  e.,  as  the  hands  of  a  watch  move  when  lying  upon 
the  floor  with  the  face  down,  and  vice  versa  for  horizontal  after- 
nystagmus  to  the  left. 

If  one  wishes  to  examine  for  rotatory  after-turning  nystagmus  to  the 
right,  the  head  should  be  inclined  90°  forward  and  the  patient  turned 
to  the  left  ( as  the  hands  of  a  watch  move  lying  upon  the  floor  with  the 
face  down),  and  vice  versa  for  rotatory  after-turning  nystagmus  to  the 
left.  After  ten  complete  turnings  the  subject  is  brought  to  a  sudden 
stop,  when  the  examiner  starts  the  watch  and  begins  to  observe  the 
nystagmus.  As  soon  as  the  nystagmus  ceases,  the  watch  is  stopped. 
If  the  observations  have  been  correct,  the  stop  watch  should  record  the 
exact  duration  of  the  after-nystagmus.  It  is  well  for  beginners  and  of 
advantage  to  the  expert,  providing  the  patient  can  tolerate  it  and  does 
not  object,  to  make  a  second  experiment  to  corroborate  the  first  find- 
ings. It  is  needless  to  add,  that  all  experiments  and  observations 
should  be  made  in  a  well  lighted  room,  and  if  necessary  a  head  mirror 
should  be  used  by  the  experimenter  to  better  illuminate  the  subject's 
eye. 

Since  both  eyes  move  in  unison,  the  observation  of  one  eye  is  gen- 
erally sufficient  to  note  the  reactions  to  both  the  right  and  the  left  side. 
It  is  well,  however,  since  exceptional  cases  of  unilateral  nystagmus  do 
occur,  to  casually  observe  the  fellow  eye. 

The  reaction  of  the  semicircular  canals  to  turning  is  in  proportion  to 
the  duration  of  the  after-nystagmus.  The  average  duration  of  after- 
turning  nystagmus  is  between  twenty  and  twenty-two  seconds  for  the 
horizontal  without  the  use  of  the  opaque  spectacles,  and  between 
twenty-three  and  twenty-six  seconds  for  the  rotatory.  With  opaque 
spectacles  fitted  before  the  subject's  eye  the  duration  of  the  horizontal 
after-nystagmus  is  considerably  lengthened  and  endures  on  an  average 
from  thirty-six  to  forty  seconds. 

The  examination  of  horizontal  after-nystagmus    with    the    opaque 


i4S  TURXIXG  AXD  AFTER-TL'KXIXG  XYSTAG.MVS. 

spectacles  is  to  be  preferred  to  that  made  without,  since  Abels  has 
pointed  out  that  convergence  of  the  eyes  inhibits  the  free  play  of  the 
vestibular  reflex.  The  writer  has  alluded  to  this  subject  before  and 
will  not  go  into  further  details  now.  Tho  the  figures  given  above  rep- 
resent the  average  duration  of  rotatory  and  horizontal  after-nystagmus 
Barany  points  out  some  wide  variations  that  he  has  found  in  some  of 
his  experiments  upon  normal  people. 

In  his  experiments  upon  200  persons,  some  normal  and  others  with 
ear  affections  but  not  complaining  of  vertigo,  he  found  the  average 
duration  of  horizontal  after-nystagmus  after  ten  turnings  to  the  left 
forty-one  seconds,  and  to  the  right  thirty-nine  seconds. 

These  figures  are  somewhat  high,  but  may  be  explained  as  due  to  the 
fact  that  many  of  those  with  ear  affections  may  have  suffered  slight 
irritation  of  their  labyrinths,  which  would  tend  to  lengthen  the  dura- 
tion of  the  after-nystagmus. 

For  the  fear  of  confusing  the  nystagmus  due  to  the  reflex  and  that 
"spontaneous  nystagmus"  met  with  in  most  individuals,  due  to  over 
strain  of  the  extra  ocular  muscles  during  attempts  to  gaze  in  extreme 
directions,  Barany  constructed  a  special  instrument  which  he  calls  i 
"Hilfinstrument  zur  Beobachtung  des  rotatorischen  Nystagmus"  to  aid 
him  in  his  observation  of  rotatory  after-nystagmus ;  illustration  and 
description  of  which  may  be  found  on  page  19  of  his  booklet.  The 
writer  has  used  this  instrument  at  the  request  of  Barany  and  discarded 
it  again.  Barany  himself  has  discarded  it  also  and  brings  it  out  only 
occasionally  to  show  the  students. 

I  do  not  consider  observations  of  after-turning  nystagmus  as  thoroly 
accurate  when  the  subject  looks  in  any  other  direction  than  straight 
ahead.  This  point  has  been  dwelt  upon  by  me  in  former  papers.  I  am 
led  to  this  conclusion  by  repeated  experiments  made  upon  more  than 
400  subjects.  Besides  I  find  that  my  figures  are  more  uniform  and  con- 
sistent than  those  of  Barany,  which  I  believe  is  due  to  the  very  fact  that 
my  observations  have  been  made  with  the  subjects  looking  straight 
ahead  instead  of  to  the  side  as  Barany's  have  been  made. 

I  have  never  been  able  to  find  the  extremely  high  figures  even  in 
cases  of  marked  labyrinth  irritation  as  Barany  has  in  some  of  his 
normal  cases  (88  and  120  seconds). 

According  to  Barany  the  duration  of  the  after-nystagmus  diminishes 
slightly  after  fifty  years  of  age ;  which  corresponds  with  the  results  ob- 
tained by  the  writer. 


LABYKIXTH  PAPERS.  149 

The  duration  of  after-nystagmus  varies  according  to  the  number  of 
times  the  subject  has  been  turned.  It  is  proportionately  less  where 
the  turnings  are  less  than  ten,  i.  e.,  the  duration  averages  less  for  two 
turns  than  for  five,  and  less  for  five  than  for  ten  turnings. 

Again  a  greater  number  of  turns  than  ten  seem  to  diminish  rather 
than  increase  the  duration  of  after-nystagmus.  For  instance,  the 
average  duration  of  after-turning  nystagmus  is  less  after  twenty  thar 
after  ten  turnings,  and  less  after  forty  than  after  twenty.  These  data 
are  important  since  they  prompt  us  to  adopt  the  method  of  Barany,  i.  e., 
to  practice  ten  turning  tests  rather  than  more  or  less  than  ten. 

Normal  subjects  generally  show  about  the  same  reaction  (duration  of 
after-nystagmus)  when  examined  repeatedly  upon  different  days. 
However,  slight  variations  have  been  found  by  Barany  which  the 
writer  believes  is  due  rather  to  his  method  of  examination — having  the 
subjects  look  laterally — than  to  an  actual  variation  in  the  semicircular 
canals'  reactions. 

In  Austria  where  people  dance  continuously  to  the  right  or  the  left, 
as  the  case  may  be,  without  reversing  Barany  found  the  physiological 
reactions  vary  somewhat  to  the  t\Vo  sides.  For  instance,  with  those 
who  dance  to  the  right,  the  duration  of  after-nystagmus  to  the  right 
was  found  to  be  of  slightly  shorter  duration  than  the  after-nystagmus 
to  the  left. 

Rapid  turnings  produce  a  more  rapid  nystagmus  both  during  and 
after  turning,  but  the  duration  of  the  after-nystagmus  does  not  vary 
from  that  produced  by  the  slower  turning.  In  some  cases  the  duration 
was  longer  and  in  other  cases  shorter  after  slow  turnings  than  after 
quicker  turnings ;  but  on  the  whole  they  average  up  about  the  same. 

Barany  refers  to  a  form  of  nystagmus  which  he  terms  "nachnach 
nystagmus"  (after-after-nystagmus).  It  occurs  not  infrequently  in 
those  who  have  been  turned  twenty  or  more  times.  In  those  cases  the 
subject  shows  first  a  very  pronounced  after-nystagmus  in  the  usual 
direction  (contrary  to  the  turnings),  which  ceases  rather  suddenly, 
followed  by  a  small  excursioned  nystagmus  in  the  opposite  direction  to 
the  after-nystagmus  (that  is,  in  the  direction  of  the  turnings  which 
produced  it)  ;  this  may  last  as  long  as  sixty  seconds.  This  form  of 
nystagmus  is  more  of  scientific  interest  than  of  practical  value. 

Since  the  semicrcular  canals  of  one  side  are  capable  of  producing 
nystagmus  to  either  side  it  becomes  a  question  of  interest  and  import- 
ance to  know  just  how  much  the  after-nystagmus  to  one  side  is  due  to 


150  TURXIXG  AXD  AFTER-TURNING  XVSTAG.MUS. 

irritation  of  the  semicircular  canals  of  the  same  side  and  how  much  to 
irritation  of  the  semicircular  canals  of  the  opposite  side. 

(1)  We  have  learned  from  Ewald's  experiments  that  mechanical 
forcing  of  the  endolymph  toward  the  ampulla  of  the  horizontal  canal 
produces  nystagmus  to  the  same  side ;  while  suction  produces  the  oppo- 
site movement  of  the  endolymph  and  with  it  the  opposite  nystagmus. 

(2)  In  a  normal  individual  it  is  impossible,  by  turning,  to  produce 
endolymph  motion  of  one  side  only. 

(3)  In  a  normal  case  with  an  after-turning  nystagmus  of  twenty- 
four  seconds  (the  approximate  normal)  duration,  it  is  apparent  (from 
the  foregoing)  that  irritation  from  the  two  sides  is  responsible  for  the 
after-nystagmus. 

(4)  If  the  same  patient  should  lose  the  labyrinth  of  one  side  from 
any  cause  it  will  be  found  that  the  after-nystagmus  to  the  well  side  will 
have  diminished  from  twenty-four  to  sixteen  seconds   (which  repre- 
sents an  average  obtained  from  an  examination  of  numerous  cases)  ; 
while  the  after-nystagmus  to  the  diseased  side  will  have  diminished 
from  twenty-four  to  approximately  eight  seconds. 

(5)  It  will  be  seen  from  the  above  figures  that  in  a  case  of  one- 
sided labyrinth  destruction  the  after-nystagmus  to  the  sound  side  is 
twice  as  long  as  the  after-nystagmus  to  the  diseased  side. 

(6)  The  greatest  common  divisor  of  the  above  figures  (8,  16,  24) 
is  8  from  which  we  may  simplify  the  solution  of  our  problem  as  fol- 
lows :  For  instance,  in  a  case  of  left-sided  destruction — 

(a)  The  duration  of  after-nystagmus  to  the  right,   representing 
irritation  of  the  right  side  only,  is  sixteen  seconds. 

(b)  In  the  same  case  the  duration  of  after-nystagmus  to  the  left, 
representing  irritation  of  the  opposite  side  only,  is  eight  seconds  or 
just  one-half  the  value  of  irritation  of  the  right  side. 

(c)  In  the  normal  case,  both  sides  intact,  the  duration  of  the  after- 
nystagmus  to  the  left,  representing  irritation   of  the  both   sides,   is 
twenty-four  seconds  or  sixteen  for  the  same  side  plus  eight  for  the 
opposite  side  making  the  total  of  twenty-four  seconds.    These  figures 
are  not  to  be  considered  exact  for  all  cases,  for  we  find  many  variations 
but  in  the  main  they  represent  a  fair  average,  demonstrating  that  after- 
turning  nystagmus  to  one  side  is  due  to  two  irritations,  two-thirds  of 
which  is  produced  by  irritation  of  the  semicircular  canal  of  the  same 
side  and  one-third  by  irritation  of  the  semicircular  canal  of  the  op- 
postt  side. 


CALORIC  NYSTAGMUS. 

CALORIC  Nystagmus  is  the  name  given  to  the  rhythmic  nys- 
tagmus which  results  from  the  application  of  heat  or  cold 
directly  (thru  a  perforation  in  the  tympanic  membrane) 
or  indirectly  (in  case  of  intact  membrane)  to  that  portion  of  the  exter- 
nal labyrinth  wall  which  forms  the  inner  wall  of  the  middle  ear  spaces. 

The  phenomenon  of  vertigo  after  lavage  of  the  middle  ear  spaces 
had  been  observed  and  reported  by  numerous  authors.  Quoting  from 
Barany,  pages  26  and  27  of  his  work — "Phys.  u.  Path,  des  Bgg.  Appar. 
beim  Menschen" : — "Smiegelow  and  Hensen  in  the  year  1868  discov- 
ered, while  experimenting  upon  the  strength  of  resistance  of  the  tym- 
panic membrane,  that  the  influence  of  cold  water  in  the  external  canal 
produced  vertigo,  nausea  and  vomiting,  while  water  at  the  body  tem- 
perature did  not.  Other  authors  have  corroborated  the  fact  that  syr- 
inging the  ear  with  too  cold  or  too  hot  water  produces  vertigo  (Cohn, 
Urbantschitsch)." 

"Baginsky,  in  the  year  1881,  made  animal  experiments,  syringing 
the  ears  of  rabbits  with  cold  water.  He  found  that  it  produced  the 
same  vertigo  and  nystagmus,  but  as  soon  as  warm  water  was  used  the 
vertigo  and  nystagmus  ceased.  Baginsky  then  increased  the  pressure 
until  the  tympanic  membrane  and  the  membranes  of  the  round  and 
oval  windows  were  ruptured  and  water  rushed  into  the  semi-circular 
canals  and  thence  into  the  brain.  Since  the  animals  died  of  menin- 
gitis, Baginsky  concluded  that  the  nystagmus  was  not  produced  from 
the  semi-circular  canals  but  from  the  brain  itself.  He  neglected  to 
observe,  however,  whether  with  the  use  of  the  cold  water  these  mem- 
branes were  always  destroyed." 

For  three  years  prior  to  1907,  Barany  investigated  thoroly  the  sub- 
ject of  caloric  nystagmus,  and  thru  his  efforts  have  been  established 
certain  definite  facts  concerning  the  reactions  of  the  ear  labyrinth  to 
heat  and  cold.  Besides,  he  has  given  us  a  theory  which  satisfactorily 
explains  all  the  phenomena  of  caloric  nystagmus.  Since  his  publica- 
tion (1907)  nothing  new  has  been  added  to  this  branch  of  the  subject 
nor  has  Barany  been  compelled  to  retract  a  single  statement.  Con- 
cerning the  theory  advanced  by  Barany  a  few  have  ventured  to  dis- 
agree, but  without  avail.  His  theory  stands  today  stronger  than  it  did 


i52  CALORIC  NYSTAGMUS. 

before  these  authors  attempted  to  disagree  with  him.  The  subject  of 
caloric  nystagmus  is  so  linked  with  Barany's  work  that  it  is  well  nigh 
impossible  to  write  upon  this  branch  of  the  subject  in  anything  like 
original  style. 

The  following  are  the  reactions  of  the  ear  labyrinth  to  heat  and  cold 
as  determined  first  by  Barany  and  since  corroborated  by  every  inves- 
tigator. 

I,  With  the  head  erect,  cold  water  (i.  e.  water  below  the  body  tem- 
perature) syringed  into  the  right  ear  produces  a  rotatory  nystamus  to 
to  the  left  or  opposite  side. 

II,  With  the  head  erect,  hot  water  (i.  e.  water  above  the  body  tem- 
perature) syringed  into  the  right  ear  produces  a  rotatory  nystagmus  to 
the  right  or  same  side. 

III,  With  the  head  inverted   (i.  e.  vertex  toward  the  floor)   cold 
water  syringed  into  the  right  ear  produces  rotatory  nystagmus  to  the 
right  or  same  side. 

IV,  With  the  head  inverted,  hot  water  syringed  into  the  right  ear 
produces  rotatory  nystagmus  to  the  left  or  opposite  side. 

V,  With  the  head  inclined  to  the  left  so  that  a  line  uniting  the  two 
eyes  stands  vertically,  cold  water  syringed  into  the  right  ear  produces 
a  horizontal  nystagmus  to  the  right  or  same  side. 

VI,  With  the  head  inclined  to  the  right,  cold  water  syringed  into 
the  right  ear  produces  a  horizontal  nystagmus  to  the  left  or  opposite 
side. 

VII,  With  the  head  inclined  to  the  left,  warm  water  syringed  into 
the  right  ear  produces  a  horizontal  nystagmus  to  the  left  or  opposite 
side. 

VIII,  With  the  head  inclined  to  the  right,  warm  water  syringed 
into  the  right  ear  produces  a  horizontal  nystagmus  to  the  right  or  same 
side. 

The  writer  was  the  first  to  observe  a  mixed  reaction  from  the  use 
of  cold  water  syringed  into  the  ear,  as  follows :  with  the  head  inclined 
obliquely  to  the  left,  cold  water  syringed  into  the  right  ear  will  pro- 
duce a  pronounced  horizontal  nystagmus  to  the  right  side  combined 
with  a  moderate  degree  of  rotatory  nystagmus  to  the  left.  In  order 
to  obtain  this  reaction,  it  is  not  necessary  to  have  the  head  held  exactly 
at  an  angle  of  45°  to  the  left,  for  the  horizontal  feature  will  be  mani- 
fested even  with  a  much  less  inclination  of  the  head.  I  cite  this  reac- 
tion for  the  purpose  of  avoiding  confusion  to  anyone  who  may  see  it 


LABYRINTH  PAPERS.  153 

for  the  first  time.  It  comes  natural  to  one  in  syringing  an  ear  to  have 
the  patient's  head  inclined  somewhat  away  from  the  operator  intro- 
ducing the  canula,  so  the  first  evidence  of  a  positive  reaction  may  be 
a  pronounced  horizontal  nystagmus  to  the  same  side.  Change  of  posi- 
tion of  the  head  to  the  erect  causes  the  nystagmus  to  change  to  the 
typical  rotatory  character  to  the  opposite  side. 

That  the  horizontal  element  predominates  in  the  case  of  the  mixed 
nystagmus  referred  to  is  due  probably  to  the  fact  that  the  horizontal 
semicircular  canal  is  more  exposed  to  the  influences  of  temperature 
changes  than  the  superior  vertical  canal. 

It  has  been  observed  that  in  the  case  of  after-turning  nystagmus, 
the  plane  and  direction  of  the  nystagmus  when  once  begun  remain 
unaltered  by  any  subsequent  change  of  position  of  the  head.  In  the 
case  of  Caloric  -Nystagmus  the  opposite  condition  holds  true,  viz. — 
a  subsequent  change  of  position  may  alter  either  the  plane  or  direc- 
tion or  both  plane  and  direction  of  the  nystagmus.  This  characteristic 
is  a  distinctive  feature  of  the  Caloric  Nystagmus. 

In  the  case  of  Galvanic  Nystagmus,  the  polarity  determines  the 
direction  and  no  change  of  position  of  the  head  will  change  either  the 

character  or  the  direction  of  the  nystagmus. 

i 

THE     THEORY     OF     BARANY. 

Briefly  put,  the  theory  of  Barany  is  as  follows : — endolymph  motion 
in  the  semicircular  canals  is  produced  by  an  increase  in  density  of  the 
fluid  in  that  part  of  the  canals  exposed  to  cold,  causing  it  to  sink ;  and 
by  the  diminution  of  the  density  of  the  fluid  in  that  part  of  the  canal 
exposed  to  heat,  causing  it  to  rise.  Let  the  labyrinth  be  represented 
by  a  vessel  filled  with  a  fluid  of  even  temperature  (37°  C.)  upon  the 
external  surface  of  which  is  played  a  stream  of  cold  water  (Fig.  i). 
The  fluid  immediately  behind  the  exposed  external  wall  is  cooled,  caus- 
ing it  to  sink  to  the  deepest  part  of  the  vessel,  while  the  uncooled  water 
above  moves  downward  to  take  its  place.  The  result  is  a  circulation 
or  tendency  to  circulation  of  the  fluid  in  the  vessel.  It  is  evident  that 
hot  water  would  produce  the  opposite  effect  to  that  produced  by  coM 
water. 

Altho  the  density  of  the  endolymph  increases  when  the  temperature 
is  reduced  below  37°  C.  (body  temperature),  we  see  in  fig.  i  that  the 
arrow  indicating  the  direction  of  the  cooled  endolymph  next  to  the 


154 


CALORIC  NYSTAGMUS. 


wall  c  is  downward  in  both  instances  (A,  vessel  upright  and  B,  vessel 
inverted),  but  in  relation  to  the  surfaces  of  the  vessels  the  direc- 
tion in  the  case  of  B  (vessel  inverted)  is  the  reverse  of  that  in  the  case 
of  A  (vessel  erect). 


/I. 


/ 

\     ^ 

| 

3fc 

/ 

$     N 

f 

1 


d 


A       * 


37  c 


A 


\f 


Cold 


FIG.  I. — Schematic  representation  of  the  vestibular  apparatus  by  a  vessel  filled 
with  a  fluid  at  a  temperature  of  37°  C.  (98.6°  F.)  ;  after  Barany. 

A.  The  direction  of  the  fluid  circulation  when  the  wall  c  is  cooled  with  a 
stream  of  cold  water.   The  vessel  is  shown  in  the  upright  position.    The  surface 
(a)  indicating  the  top  and  the  surface  (b)  indicating  the  bottom  of  the  vessel. 

B.  The  direction  of  fluid  circulation  when  the  wall  c  is  cooled  with  a  stream 
of  cold  water.     The  vessel  is  here  indicated  in  the  inverted  position;  the  bot- 
tom  (b)  is  above  and  the  top  (a)  is  below. 

In  order  to  fix  more  closely  in  the  mind  the  caloric  reactions,  the 
writer  has  made  use  of  two  other  illustrations — figures  2  and  3. 

In  figure  2  is  represented  the  right  membranous  labyrinth  viewed 


LABYRIXTH  PAPERS. 


155 


from  the  external  surface  with  the  head  erect.  In  this  position  the 
external  canal  lies  approximately  in  the  horizontal  plane,  hence  the 
application  of  heat  or  cold  produces  but  little  or  no  effect  upon  the 
endolymph  contained  within  it.  The  superior  canal,  on  the  contrary, 
lies  approximately  in  a  vertical  plane  and  the  endolymph  within  it  must 
necessarily  be  more  subject  to  upward  and  downward  movements  from 
temperature  changes  than  in  the  case  of  the  external  canal. 


FIG.  2. — Schematic  representation  of  the  right  membranous  labyrinth  viewed 
from  the  external  surface  with  the  subject  in  the  erectposition.  C,  cochlea ; 
S,  sacculus ;  U,  urticulus ;  APC,  ampulla  of  the  posterior  semicircular  canal ; 
PSCC.  posterior  semicircular  canal;  ESCC,  external  semicircular  canal;  SE, 
saccus  endolymphaticus ;  AEC,  ampulla  of  the  external  semicircular  canal ; 
ASC,  ampulla  of  the  superior  semicircular  canal;  H,  highest  point  of  the 
superior  semicircular  canal;  SSCC,  superior  semicircular  canal;  CP,  common 
portal  of  the  superior  and  posterior  semicircular  canals.  The  dotted  arrow 
indicates  the  direction  of  endolymph  circulation  during  the  application  of  cold. 
The  full  arrow  indicates  the  direction  of  endolymph  circulation  during  the  appli- 
cation of  heat. 

tion  in  this  direction  to  the  same  effects  produced  by  the  mechanical 
A  play  of  cold  water  upon  the  inner  wall  of  the  middle  ear  will  cool 
the  endolymph  in  the  utriculus  and  the  external  crus  of  the  superior 
canal.  The  cooled  endolymph  sinks  in  the  direction  indicated  by  the 
dotted  arrow.  We  have  but  to  compare  the  effect  of  endolymph  mo- 


i56  CALORIC  NYSTAGMUS. 

experiments  of  Ewald  or  to  those  produced  by  turning  to  the  left 
with  head  inclined  90°  forward  to  determine  the  results.  In  all  three 
cases  inclination  of  the  cilia  of  the  crista  ampullaris  toward  the  utricu- 
lus  is  produced  and  with  it  a  rotatory  nystagmus  in  the 
opposite  direction  of  the  inclination  (to  left 
side). 

From  what  has  already  been  said,  it  is  evident  that  the  application 
of  heat  produces  the  opposite  endolymph  motion,  indicated  by  the  full 
arrow,  and  with  it  a  rotatory  nystagmus  in  the  same 
direction  of  the  inclination  (to  the  right  side). 


ESCC 


FIG.  3. — Schematic  representation  of  the  right  membranous  labyrinth  viewed 
from  below,  the  position  it  is  in  when  the  head  is  inclined  to  left  90°  (left  side 
of  the  face  resting  upon  the  left  shoulder).  C,  cochlea;  S,  sacculus ;  U, 
utriculus ;  A  PSC,  ampulla  of  the  posterior  semicircular  canal ;  P  S  C  C, 
posterior  semicircular  canal ;  ESCC,  external  semicircular  canal ;  S  S  C  C, 
superior  semicircular  canal ;  H,  most  superior  part  of  the  external  semicircular 
canal ;  A  E  C,  ampulla  of  the  external  semicircular  canal ;  A  S  C  C,  ampulla  of 
the  superior  semicircular  canal ;  C.  P.,  common  portal  of  the  superior  and  pos- 
terior semicircular  canals.  The  dotted  arrow  indicates  the  direction  of  endo- 
lymph circulation  during  the  application  of  cold.  The  full  arrow  indicates  the 
direction  of  endolymph  circulation  during  the  application  of  heat. 

In  figure  3  is  represented  the  right  membranous  labyrinth  in  the 
position  it  occupies  when  the  head  is  inclined  laterally  90°  to  the  left. 
The  external  surface  is  directed  upward.  In  this  position  the  external 


LABYRINTH  PAPERS.  157 

canal  lies  approximately  in  a  vertical  plane  and  for  this  reason  particu- 
larly the  application  of  heat  or  cold  must  produce  the  maximum  amount 
of  endolymph  motion  in  this  canal.  There  are  other  reasons  too  for 
this  maximum  of  endolymph  motion  in  the  external  canal  rather  than 
in  the  superior  canal,  which  also  lies  in  a  vertical  plane  at  right  angles 
to  the  external  canal ;  ( i )  that  the  highest  point  in  the  external  canal 
is  higher  than  the  highest  point  in  the  superior  canal,  and  (2)  it  lies 
nearer  to  the  point  of  application  of  the  heat  or  cold  than  the  superior 
canal.  A  play  of  cold  water  upon  the  inner  wall  of  the  middle  ear  will 
cool  the  endolymph  in  the  utriculus  and  the  exposed  part  of  the  exter- 
nal crus.  The  cooled  endolymph  must  sink  in  the  direction  indicated 
by  the  dotted  arrow.  Again  we  have  but  to  compare  the  effects  of 
endolymph  motion  toward  the  ampulla  and  utriculus  in  the  case  of  the 
external  canal  with  those  produced  by  Ewald's  pneumatic  hammer  by 
compression  or  by  turning  to  the  right  with  the  head  erect  in  order  to 
determine  the  results.  All  three  produce  inclination  of  the  cilia  of  the 
crista  ampullaris  toward  the  utriculus  and  with  it  a  horizontal 
nystagmus  to  the  same  side  (right). 

If  the  play  of  cold  water  upon  the  labyrinth,  with  the  head  in  this 
position,  produces  horizontal  nystagmus  to  the  same  side  then  it 
follows  that  hot  water  must  produce  the  opposite  effect,  viz. — endo- 
lymph motion  in  the  horizontal  canal  in  the  opposite  direction  indi- 
cated by  the  full  arrow  and  with  it  a  horizontal  nystagmus 
to  the  oppostte  side  (left). 

Opposite  effects  to  those  enumerated  are  produced  by  change  of 
position  of  the  head  180°.  Furthermore,  the  direction  and  plane  of 
the  nystagmus  may  be  definitely  changed  by  altering  the  position  of 
the  head  even  after  the  reaction  has  once  begun.  This  feature  is 
characteristic  alone  for  this  form  of  irritation  which  was  alluded 
to  earlier  in  the  paper  and  is  one  of  sufficient  importance  to  bear  this 
reiteration. 

The  caloric  reaction  of  the  labyrinth  is  positive  when  nystagmus 
results  and  negative  when  nystagmus  does  not  result.  We  therefore 
find  the  reaction  positive  in  normal  labyrinths  and  all  pathologic  con- 
ditions which  fall  short  of  complete  destruction.  We  find  the  reaction 
negative  in  complete  destruction  of  the  labyrinth  and  complete  disa- 
bility of  the  nerve,  be  it  temporary  or  permanent.  But  one  thing  it 
does  not  tell  and  that  is  the  intensity  of  an  existing  pathologic  process 
in  the  labyrinth  when  that  process  is  other  than  a  complete  destruction. 


1 58  CALORIC  NYSTAGMUS. 

In  other  words,  the  caloric  test,  altho  a  perfectly  satisfactory  qualita- 
tive test,  is  in  no  way  a  quantitative  one  like  the  turning  and  galvanic 
tests. 

METHOD   OF    MAKING   THE    CALORIC    TEST. 

The  caloric  test  may  be  made  with  either  water  or  air  injected  into 
the  canal  or  better,  when  possible,  directly  into  the  tympanic  cavity. 

Since  water  is  capable  of  carrying  a  greater  number  of  heat  units 
to  and  from  the  parts  than  air  or  vapors,  it  is  naturally  better  suited 
for  the  purpose.  In  fact,  for  a  patient  to  react  at  all  promptly  to  the 
caloric  test  with  the  use  of  air  or  vapors  it  would  be  necessary  to 
have  a  suitable  generator,  the  simplest  of  which  would  necessarily  be 
quite  complex  in  structure.  I  would  hardly  advise  the  use  of  ethyl 
chloride  vapor  since  it  is  impossible  to  regulate  the  temperature  satis- 
factorily and  harm  can  be  done.  In  fact  I  have  never  made  a  test  with 
air  or  vapor  nor  have  I  seen  or  read  of  anyone  else  making  any.  The 
investigations  of  Barany,  Alexander,  Neumann,  Ruttin  and  myself 
have  all  been  made  with  water,  which  is  quite  simple  to  make  and  the 
most  satisfactory. 

The  selection  of  the  temperature  of  the  water  to  be  used.  Remem- 
bering that  the  temperature  of  the  endolymph  in  the  canals  is  about 
that  of  the  body  (between  98.6°  and  100°  F.),  it  is  evident  that  in 
order  to  obtain  a  positive  reaction  from  heat  we  must  use  water  the 
temperature  of  which  is  at  least  10  degrees  higher.  This  temperature 
can  be  borne  comfortably  by  the  patient.  An  increase  of  10  degrees 
more,  however,  is  about  the  limit  which  the  patient  can  tolerate.  A 
difference  of  20  degrees  then  is  about  the  limit  of  high  temperature 
for  water  to  be  used  in  making  a  caloric  examination.  This  difference 
is  sufficient  to  produce  a  caloric  reaction  under  favorable  circum- 
stances ;  i.  e.,  large  perforation  in  the  tympanic  membrane,  the  absence 
of  excessive  granulations  or  cholesteatomatous  masses,  marked  thick- 
ening of  the  mucous  membrane,  acute  inflammation  or  acute  exacerba- 
tion of  a  chronic  inflammation  or  high  fever. 

Alexander  pointed  out  the  importance  of  fever  upon  this  reaction. 
A  patient  suffering  from  a  chronic  middle  ear  suppuration  with  a  large 
perforation  and  without  fever  may  react  promptly  today  with 
water  at  the  temperature  of  118°  F.,  but  tomorrow  with  the  patient 
suffering  fever  (104°,  105°  or  106°),  water  of  118°  may  fail  to 
produce  a  positive  reaction  while  the  labyrinth  condition  has  remained 
unchanged. 

The  use  of  hot  water  is  not  so  trustworthy  for  testing  the  labyrinth- 


LABYRINTH  PAPERS.  159 

ine  function  as  is  the  use  of  cold  water.  The  cold  water  is  by  far  the 
more  satisfactory,  and  is  used  almost  exclusively  by  all  investigators, 
the  reason  being  that  a  greater  variation  of  temperature  from  the  nor- 
mal (98.6°  F.)  may  be  applied  without  any  discomfort  to  the  patient. 
Water  at  the  temperature  of  68°  can  be  comfortably  borne  by  the 
patient ;  besides,  the  density  of  the  endolymph  is  considerably  influenced 
by  this  difference  (30°)  of  temperature.  Lower  temperatures  may 
however  be  employed  and  tolerated,  but  these  lower  temperatures  are 
not  necessary  except  in  a  small  percentage  of  cases  presenting  certain 
obstacles :  atresia  of  the  canal,  acute  narrowing  of  its  lumen,  foreign 
bodies  in  the  canal,  tumors,  intact  membrane,  small  perforations,  acute 
inflammation  of  the  tympanic  cavity,  excessive  amount  of  granulations 
or  cholesteatomatous  masses. 

The  use  of  water  in  the  ear  is  generally  contra-indicated  in  cases  of 
healed  middle  ear  suppuration  with  remaining  dry  perforation. 

METHOD      OF      APPLYING      THE      TEST. 

Before  beginning  the  test  it  is  necessary  to  note  the  presence  or  ab- 
sence of  spontaneous  nystagmus,  and  when  present  its  character,  plane 
and  direction.  Ascertain  too  the  positions  of  the  eyeballs  at  which  the 
spontaneous  nystagmus  is  most  and  least  pronounced.  It  is  well  to 
have  one  observer  to  direct  the  gaze  of  the  patient  and  observe  the 
reaction.  The  finger  of  the  observer  may  be  used  for  the  purpose  or 
a  specially  designed  instrument  of  Barany  known  as  the  Hilfsinstru- 
ment,  or,  better  still,  have  the  patient  look  at  a  distant  point  (say 
a  nail  in  the  wall).  A  second  operator  applies  the  stream  of  water 
into  the  canal  or  better,  where  possible,  directly  into  the  tympanic  cav- 
ity. The  instrument  used  in  the  Politzer  and  Alexander  clinics  and 
by  the  writer,  consists  of  a  Politzer  bag  attached  to  a  soft  rubber  tube 
about  one  foot  long  and  on  the  distal  end  of  this  tube  is  fitted  a  Hart- 
man's  attic  canula.  The  safest  and  surest  method  of  introducing  the 
canula  properly  is  with  the  aid  of  a  speculum  and  head  mirror.  The 
introduction  and  holding  of  the  speculum  in  place  occupies  one  hand 
of  the  second  operator  and  the  introduction  of  the  canula  his  other 
hand.  Someone  else  (a  third  party)  must  elevate  and  squeeze  the 
Politzer  bag  containing  the  water.  Since  this  requires  no  especial 
skill,  it  may  be  done  by  a  nurse  or  friend  accompanying  the  patient. 

I  have,  however,  occasionally  managed  without  any  assistant,  but  it 
is  never  so  satisfactory  as  when  you  have  one  and  better  when  you 
have  two. 


160  CALORIC  NYSTAGMUS. 

It  is  especially  desirable  to  have  one  trained  assistant  at  least,  to 
either  observe  the  first  signs  of  reaction  (nystagmus)  while  you  intro- 
duce the  canula  or  vice  versa.  Since  the  caloric  reaction  is  sometimes 
quite  violent  and  unpleasant,  it  is  well  to  note  the  reaction  directly  it  is 
manifested  and  then  be  prepared  to  control  it  promptly.  As  soon  as 
the  reaction  is  sufficiently  pronounced  to  be  sure  of  its  presence,  imme- 
diately detach  the  balloon  containing'  the  cold  water  and  substitute  for 
it  one  containing  warm  water.  The  play  of  warm  water  soon  counter- 
acts the  effects  of  the  cold. 

This  is  the  practice  of  the  writer  and  one  which  he  strongly  recom- 
mends for  the  comfort  of  the  patient. 

At  this  juncture  I  would  further  suggest  that  directly  you  have  ob- 
served the  cold  water  reaction  (rotatory  nystagmus  to  the  opposite 
side)  that  you  direct  the  patient  to  look  to  the  side  away  from  his  nys- 
tagmus in  order  to  diminish  the  intensity  of  the  accompanying  vertigo 
along  with  its  tram  of  unpleasant  sensations. 

In  making  the  cold  water  test  the  first  sign  of  reaction  may  be  the 
gradual  increasing  of  an  existing  spontaneous  nystagmus,  or  it  may 
be  the  beginning  of  a  nystagmus  which  had  not  existed  spontaneously. 
After  withholding  the  cold  water  it  will  be  seen  that  the  nystagmus 
which  began  quite  mildly  at  first  increases  in  intensity  until  it  reaches 
its  maximum.  This  occurs  frequently  as  late  as  30  seconds  after  the 
discontinuance  of  the  cold  water.  It  is  for  this  reason  that  I  adopted 
early  the  plan  referred  to  above,  of  counteracting  the  effects  of  cold 
water  with  the  immediate  use  of  warm  water. 

The  examination  of  the  caloric  irritability  of  the  labyrinth  may  be  con- 
ducted with  the  patient  sitting  up  or  lying  down.  It  is  generally  more 
satisfactory  to  examine  the  patient  while  sitting  up.  The  exami- 
nation of  the  patient  while  lying  in  bed  is  very  unhandy,  since  a  portable 
light  is  necessary  for  illumination  and  considerable  care  must  be  exer- 
cised to  avoid  getting  the  bed  wet.  These  obstacles  however  can  be 
more  or  less  overcome  or  overlooked  by  an  examiner  who  is  bent  upon 
his  task.  There  are  certain  cases  where  the  patient's  physicial  condition 
will  not  permit  the  test  being  made  in  the  sitting  posture.  Take,  for 
instance,  a  patient  in  a  comatose  or  semicomatose  condition;  for  this 
character  of  case  the  examination  in  bed  will  be  found  to  be  especially 
suited. 

Concerning  the  examination  of  these  cases,  we  must  not 
forget  that  a  positive  reaction  in  a  comatose 


LABYRINTH  PAPERS.  161 

patient  is  manifested  by  a  conjugate  deviation 
of  the  eyes  in  the  direction  contrary  to  that  of 
the  nystagmus  which  the  patient  would  have 
shown  had  he  been  normally  conscious. 

There  are  some  obstacles  to  the  carrying  out  of  the  caloric  test  in 
some  cases,  among  which  may  be  mentioned : — 

I,  A  completely  occluded  canal  from  (a)  congenital  atresia;  (b) 
the  presence  of  a  large  foreign  body;  (c)  the  presence  of  a  large  fur- 
uncle in  the  cartilaginous  canal;  (d)  the  presence  of  a  periosteal  or 
subperiosteal  swelling  in  the  osseous  canal  in  cases  of  mastoid  abscess ; 
(e)   exostoses,  tumors,  etc.     In  these  cases  it  is  often  impossible  to 
bring  the  water  near  enough  to  the  parts  to  produce  effect. 

II,  The   presence  of   excessive  granulations   springing   from   the 
tympanic  cavity,  reaching  well  into  the  external  canal,  may  prevent 
or  hinder  the  entrance  of  water  into  the  tympanic  cavity.     In  other 
less  pronounced  cases  the  position  of  the  polyps  may  hinder  the  water 
from  reaching  the  inner  wall  of  the  middle  ear  and  thus  at  least  delay 
the  reaction.     It  is  well  in  these  cases  to  use  water  of  a  lower  tem- 
perature and  for  a  longer  period  (3  to  5  minutes).     Sometimes  a  pro- 
nounced reaction  may  be  obtained  after  three  or  five  minutes  when  a 
shorter  length  of  time  would  have  failed  completely. 

III,  Cholesteatoma,  since  it  breaks  up  readily  under  the  influence 
of  a  fairly  continuous  stream,  seldom  presents  an  obstacle  sufficient  to 
prevent  a  reaction ;  but  it  frequently  delays  it. 

IV,  Acutely  inflamed  tympanic  cavity  with  a  red  swollen  mem- 
brane either  intact  or  with  a  small  perforation  delays  the  reaction  con- 
siderably and  an  unpersistent  examiner  may  after  two  minutes'  trial 
either  give  up  or  decide  that  the  labyrinth  is  nonreactive,  whereas  a 
second  trial  with  colder  water  used  over  a  longer  period  may  succeed 
in  bringing  about  a  typically  positive  reaction. 

There  is  one  caution  that  might  be  suggested  to  a  beginner  and 
that  is  to  be  careful  in  every  case  with  a  normal  membrane.  The 
writer  saw  two  cases  of  middle  ear  suppuration  produced  by  careless- 
ness on  the  part  of  students  in  the  introduction  of  the  canula.  The 
complication  was  the  result  of  direct  rupture  of  the  membrane  by  the 
canula  together  with  the  bad  effects  of  the  water  which  had  found  its 
way  into  the  tympanic  cavity.  It  is  a  well  known  fact  that  water 
introduced  into  the  tympanic  cavity  through  a  traumatic  rupture  results 
practically  always  in  suppuration  of  the  middle  ear.  Such  a  mishap 
is  of  such  importance  that  the  writer  feels  justified  in  mentioning  it. 
n 


GALVANIC    NYSTAGMUS. 

ACCORDING  to  L.  William  Stern  (Arch.  f.  Ohrenheilk.,  Band 
xxxix,  pages  248-284)  the  first  one  to  investigate  the  ef- 
fects of  the  galvanic  current  in  producing  vertigo  was  Ritter 
in  1803.  The  results  of  Ritters  investigation  were  published  in  Hufe- 
land's/owrna/  /.  prakt.  Heilk.,  bd,  xvn,  3  stueck,  s.  34,  under  the  title 
of  "Ueber  die  Anwendung  der  Yoltaischen  Saule."  Nearly  three- 
fourths  of  a  century  later,  E.  Hitzig,  1871,  published  the  results  of  his 
experiments  in  an  article  entitled  "Ueber  die  biem  Galvanisiren  des 
Kopfes  entstehenden  Stoerungen  der  Muskelinnervation  und  der  Vor- 
steilungen  von  Verhalten  in  Raume" — Reichert  und  Dubois'  Arch.,  ?. 
716-770.  Hitzig  was  the  first  to  observe  that  the  application  of  gal- 
vanic electricity  to  the  sides  of  the  head  caused  vertigo,  the  subjective 
sensation  of  objects  rolling  to  the  side  of  the  kathode,  and  that  with 
the  use  of  the  stronger  currents  the  subjects  tended  to  fall  towards 
the  side  of  the  anode.  His  observations  were  correct  and  have  since 
been  amply  corroborated.  He  failed,  however,  to  observe  the  asso- 
ciated nystagmus,  which  must  have  been  present,  to  the  side  of  the 
kathode.  He  explained  the  reaction  as  due  to  cerebral  irritation ;  falsi- 
fication of  the  muscle  sense. 

E.  Hitzig,  1874,  wrote  a  second  article  entitled  "Untersuchungen 
ueber  das  Gehirn" — Berlin,  which  was  a  polemic  against  the  Mach- 
Breuer  theory ;  pointing  out  that  their  theory  did  not  explain  galvanic 
vertigo.  In  this  he  was  supported  by  Kny,  1887  ("Untersuchungen 
ueber  den  galvanischen  Schwindel." — Arch.  f.  Psyschiatrie,  xvm,  s.  637- 
58),  who  claimed  that  galvanic  vertigo  was  not  dependent  upon  the 
semicircular  canals. 

J.  R.  Ewald,  1890,  "Die  Abhaengigkeit  des  galvanischen  Schwindels 
vom  inneren  Ohr"  (Cent^alblatt  f.  d.  Med.  Wissenschaft,  xxvni,  s.  753- 
755),  found  that  pigeons  with  completely  extirpated  inner  ears  did  not 
manifest  galvanic  vertigo. 

Both  Hitzig  and  Ewald  made'  careful  and  accurate  observations. 
Their  conclusions  were  correct  as  far  as  they  had  gone,  in  spite  of 
their  apparent  contradictions. 

The  writer,  in  making  extensive  examinations  with  the  galvanic  cur- 
rent, has  met  with  these  same  apparent  contradictions  and  explained 
them  in  a  subsequent  part  of  this  paper. 


LABYRINTH  PAPERS.  163 

J.  Pollak — "Ueber  den  galvanischen  Schwindel  bei  Taubstummen" 
(Pflueger's  Arch.  LIV,  s.  188-207,  1893) — found  that  normal  people 
show  upon  the  application  of  the  galvanic  current  to  the  head  typical 
head  and  eye  movements  which  are  not  present  in  about  30  per  cent,  of 
deaf  mutes.  He  concluded  that  the  cause  of  the  reaction  must  be  in  the 
v^stibular  apparatus. 

Alexander  and  Kreidl,  "Ueber  die  Beziehungen  der  galvanischen 
Reaction  zur  angebornen  und  erworbenen  Taubstummheit"  (Arch  f. 
die  ges.  Physiologic,  bd.  89,  seite  475-492,  1902),  examined  deaf  mutes 
with  the  galvanic  current.  Their  method  was  to  apply  the  two  elec- 
trodes to  the  opposite  sides  of  the  head,  always  using  the  kathode  to  the 
right  ear  and  the  anode  to  the  left.  They  considered  only  the  reaction 
movements  of  the  subjects  and  did  not  make  any  observations  of  the 
nystagmus  reaction.  They  noted  the  head  movement  by  the  opening 
and  closing  current  of  30  milliamperes.  The  reaction  was  considered 
positive  when  by  closing  the  current  the  head  moved  toward  the  anode 
and  when  by  opening  the  current  the  head  moved  toward  the  kathode. 

Barany — "Phys.  u.  Path,  des  Bogengang  Appar.  beim  Menschen," 
Wein,  1907,  page  34-36 — gives  a  brief  outline  of  the  improved  method 
for  the  examination  of  the  galvanic  nystagmus  of  each  ear  separately 
and  cites  Neumann's  experiment  of  galvanization  of  the  vmth  nerve 
stump  after  operation ;  however  he  concluded  that  the  galvanic  method 
of  examination  was  of  no  practical  value. 

Neumann's  experiment,  cited  by  Barany,  was  made  in  the  Politzer 
Clinic,  1906.  He  found  after  an  operation  for  the  extirpation  of  the 
labyrinth,  that  the  nerve  stem  reacted  to  the  negative  electrode  when 
introduced  into  the  wound  cavity,  which  in  a  measure  supports  the 
previous  claim  of  Hitzig  and  Kny ;  that  galvanic  nystagmus  can  be  pro- 
duced independently  of  the  semicircular  canals.  Had  Neumann  tried 
the  experiment  several  weeks  or  months  later,  he  would  not  have  found 
this  reaction  present  because  of  the  secondary  degeneration  of  the  nerve 
which  follows  extirpation  of  the  labyrinth.  Neumann's  results  then 
would  have  corroborated  the  results  of  Ewald's  experiments  upon 
pigeons  and  those  of  Pollak  and  my  own  upon  a  certain  per  cent,  of 
deaf  mutes. 

Alexander  and  MacKenzie — "Functional  examination  of  the  organ 
of  hearing  in  deaf  mutes,"  translation  from  the  German,  Arch,  of  Oto\., 
vol.  xxxvni.  no.  6,  1908 — examined  deaf  mutes,  using  the  same  ma- 
terial as  was  used  by  Pollak,  Kreidl  and  Alexander.  They  found  that 


:64  GALVANIC  NYSTAGMUS. 

22  out  of  51  cases  showed  absolutely  no  reaction  with  12  ma. ;  a  few  of 
these  might  have  shown  a  positive  reaction  with  a  stronger  current. 

About  this  time  (1908),  the  writer  published  the  results  of  his  ex- 
periments upon  a  variety  of  cases  under  the  title,  "Klinische  Studien 
uber  die  Functionspruefung  des  Labyrinthes  mittles  des  Galvanischen 
S'romes"  (Arch.  f.  Ohrcnhcilk.,  bd.  77  and  78,  1908).  The  method 
employed  by  Alexander  and  MacKenzie  was  according  to  the  method 
cited  in  this  paper. 

There  are  two  methods  of  producing  galvanic  vertigo  and  nystag- 
mus :  ( i )  by  the  two  electrodes  applied  to  opposite  sides  of  the  head ; 
kathode  to  one  side  and  anode  to  the  opposite  side.  This  was  the  first 
method  employed.  By  this  method  a  much  weaker  current  is  required 
to  produce  a  reaction  than  by  the  second  method  to  be  described.  The 
first  method  will  produce  a  positive  reaction  in  normal  cases  with  a 
current  strength  of  from  2  to  4  ma.  The  reaction  consists  of  (a) 
rotatory  nystagmus  to  the  side  of  the  kathode;  (b)  sensation  of  the 
room  rolling  to  the  side  of  the  kathode  (pointed  out  first  by  Hitzig)  ; 

(c)  sensation  of  falling  in  the  sagittal  plane  to  the  side  of  the  kathode; 

(d)  actual  falling  takes  place  to  the  side  of  the  anode  (pointed  out  first 
by  Hitzig).    This  falling  Barany  terms  reaction  falling  and  he  claims 
it  is  produced  by  the  nystagmus ;  but  Ewald  claims  it  is  due  to  hyper- 
tonus  of  the  voluntary  muscles  of  the  side  of  the  body  corresponding 
to  the  kathode  or  to  hypotonus  of  the  side  of  the  body  corresponding  to 
the  anode. 

By  this  first  method  the  two  sides  are  irritated  simultaneously  (the 
'one  by  the  kathode,  the  other  by  the  anode)  and  it  is  impossible  to  tell 
exactly  in  cases  of  pathologic  imbalance,  which  side  is  pathologically 
under  or  over  irritable. 

The  untrustworthiness  of  this  first  method  for  the  examination  of 
each  side  separately  gave  rise  to  the  second  method,  i.  e.,  the  applica- 
tion of  one  electrode  to  the  region  of  one  ear  and  the  other  to  some 
distant  part,  preferably  away  from  the  head.  Unfortunately  the 
wider  the  separation  of  the  electrodes  the  more  the  resistance  is  in- 
creased and  naturally  the  stronger  the  current  must  be  applied  to  pro- 
duce the  same  reaction.  Barany  found  it  necessary  to  use  a  current 
strength  of  from  10  to  20  ma.  to  produce  a  marked  reaction  by  this 
second  method.  The  writer,  on  the  other  hand,  has  been  able  to  pro- 
duce distinctly  visible  reactions  with  a  very  much  weaker  strength  of 
current — from  4  to  8  ma. 


LABYRINTH  PAPERS.  165 

The  writer  considers  the  technique  of  considerable  importance  in 
making  the  galvanic  reaction,  and  for  this  reason  will  describe  briefly 
the  method  which  he  employs.  The  method  has  been  described  before 
in  some  of  his  writings ;  however,  to  save  the  readers  time  in  looking  it 
up  we  shall  review  it  here. 

W  h  a  t  is  required  ? — A  suitable  wall  plate  with  an  accurate 
milliampere-meter,  with  the  scale  sufficiently  large  to  be  plainly  seen. 
Two  electrodes — one  large  and  flat,  the  other  small  (i  cm.  in  diameter) 
and  rounded,  fitted  into  a  handle  with  an  interrupting  adjustment,  with 
cords  of  at  least  2  meters  length.  The  wall  plate  should  be  fitted  too 
with  a  reversing  switch  to  change  the  polarity. 

An  assistant  is  necessary  to  control  the  various  switches  of  the  wall 
p!ate  and  observe  the  milliampere-meter. 

Good  illumination,  preferably  from  a  head  mirror  to  be  worn  by  the 
observer.  In  using  the  head  mirror  it  is  necessary  to  have  a  light 
placed  behind  the  subject's  head.  Care  should  be  taken  not  to  reflect 
the  light  too  strongly  into  the  eyes.  I  try  as  far  as  possible  to  direct 
the  light  slantwise  on  the  eyeball  and  focus  on  the  sclera  above  the 
cornea,  so  that  a  minimum  amount  of  light  enters  the  pupil. 

The  subject  should  be  seated  comfortably  in  a  chair  close  to  the  wall 
plate  and  should  be  told  that  the  examination  is  not  painful ;  any 
anxiety  the  patient  may  have  concerning  the  examination  should  be 
allayed.  The  operator  should  stand  facing  the  subject,  slightly  to  the 
left  when  examining  the  left  side  and  slightly  to  the  right  when  ex- 
amining the  right  side.  This  is  done  in  order  to  allow  the  patient  to 
look  straight  ahead  over  the  observer's  shoulder,  at  some  distant 
point.  Abel's  opaque  spectacles  are  not  needed  in  this  examination. 
In  order  to  see  the  sclera  above  the  cornea  it  is  well  to  have  the  sub- 
ject's head  inclined  somewhat  backward  (15°  to  20°).  It  might  be 
added  that  the  reaction  is  not  governed  in  the  least  by  the  position  of 
the  head.  In  other  words,  the  character  and  the  direction  of  the 
nystagmus  are  the  same  no  matter  to  which  position  the  head  may  be 
put.  The  subject  should  fix  his  gaze  upon  some  small  object  on  the 
opposite  wall. 

As  a  preliminary,  the  observer  should  note  carefully  whether  spon- 
'aneous  nystagmus  is  present  or  not,  and  if  present  its  character,  direc- 
tion and  intensity.  The  observation  of  nystagmus  should  always  be 
made  with  the  upper  lid  passively  elevated  by  the  thumb  of  the  ob- 
server, taking  care  not  to  touch  the  eyeball  or  lid  edges.  It  must  not 


166  GALVANIC  NYSTAGMUS. 

be  forgotten  that  the  eyeball,  when  too  long  exposed  tends  to  become 
dry  and  this  is  uncomfortable  to  the  patient.  To  avoid  this,  the  writer 
frequently  lowers  the  upper  eyelid  momentarily  at  regular  intervals. 

It  is  always  essential  to  have  the  parts  where  the  electrodes  are  to  be 
applied  thoroly  moistened  with  warm  salt  water  (too  much  cannot  be 
used)  and  also  the  sponges  of  the  electrodes  should  be  kept  dripping 
wet  with  the  same  solution.  It  is  my  practice  to  place  the  large  flat 
electrode  in  the  right  hand  of  the  subject  to  be  held  there  thruout  the 
examination.  I  do  not  consider  it  necessary  to  change  hands  when 
examining  the  opposite  ear ;  I  have  never  been  able  to  note  any  differ- 
ence whatever  between  using  the  one  hand  and  the  other  or  whether 
the  right  hand  was  used  when  examining  the  same  or  the  opposite  ear. 
The  handle  of  the  second  electrode  is  held  in  the  right  hand  of  the 
examiner  when  examining  the  left  ear,  the  small,  sponge,  end  is  placed 
just  in  front  of  the  tragus.  The  examiner's  left  hand  rests  upon  the 
frontal  region  of  the  subject's  head  and  with  the  thumb  is  free  to 
move  the  upper  lid  of  the  left  eye  which  is  gently  elevated  to  uncover  a 
fair  portion  of  the  sclera  above  the  cornea.  The  current  is  started  by  the 
assistant  gradually  increasing  the  strength  until  a  reaction  is  observed, 
then  I  say  to  the  assistant  "reaction  present  to  the  left,  or  right" — as  the 
case  may  be — and  he  notes  the  reading  of  the  milliampere  meter,  call- 
ing it  off  to  me,  and  tells  me  too  if  the  direction  of  the  nystagmus 
as  I  find  it,  corresponds  with  the  polarity  used. 

Up  to  this  time  I  have  not  allowed  myself  to  know  the  polarity,  which 
is  controlled  by  a  switch  in  the  hand  of  the  assistant.  This  is  done  so 
that  I  may  not  be  governed,  in  the  least,  in  deciding  the  direction  that 
the  nystagmus  should  take;  thereby  helping  to  eliminate  the  socalled 
personal  equation  factor.  Curiosity  naturally  prompts  me  to  know 
afterwards,  and  I  find  myself  looking  at  the  instrument.  This  is  done, 
too,  to  see  that  the  assistant,  should  he  be  new  at  the  work,  has  done 
his  part  correctly. 

So  we  proceed  examining  first  one  ear  with  both  the  anode  and 
kathode,  then  the  other  ear,  often  repeating  the  examination  on  the 
same  individual  two  or  three  times  to  be  absolutely  certain  of  our  re- 
sult. After  making  this  examination,  occasionally  coincident  with  it, 
an  examination  of  the  opening  and  closing  nystagmus  is  made,  using 
about  the  same  strength  of  current  or  a  little  less  than  was  required  to 
cause  the  first  reaction. 

In  making  the  galvanic  nystagmus  examination,  I   frequently  in- 


LABYRINTH  PAPERS.  167 

struct  the  patients  to  tell  me  of  their  subjective  sensations,  i.  e.,  to 
which  side  they  saw  the  room  rolling  or  to  which  side  they  felt  they 
were  falling,  remembering  that  both  of  these  sensations  are  to  the  side 
cf  the  kathode  or  away  from  the  anode  and  to  the  side  corresponding 
to  that  of  their  nystagmus. 

The  reaction  may  manifest  itself  in  different  ways  according  to  cir- 
cumstances. 

The  normal  individual  without  spontaneous  nystagmus,  except  in  the 
extreme  lateral  position  of  the  eyeballs,  should  show  when  looking 
straight  ahead : 

(a)  Rotatory  rythmic  nystagmus  to  the  same  side  when  the  kathode 
is  used  with  a  current  strength  of  from  4  to  8  ma. 

(b)  Rotatory  rythmic  nystagmus  to  the  opposite  side  when  the  anoc'e 
is  used,  and  with  a  current  strength  equal  to  that  required  to  produce 
the  same  degree  of  nystagmus  to  the  same  side  when  the  kathod?  is 
used. 

Normal  people  should  show  a  perfect  balance  of  reactions  to  the  two 
sides  and  an  equal  balance  between  the  kathode  and  anode  ;  for  instance, 
if  4  ma.  kathode  to  the  left  side  produces  rotatory  nystagmus  to  the 
left  side,  then  4  ma.  anode  to  the  left  side  should  produce  the  same  de- 
gree of  nystagmus  to  the  (opposite)  right  side  and  4  ma.  kathode  to  the 
right  side  should  produce  the  same  degree  of  nystagmus  to  the  right 
side.  This  is  true  of  course  only  when  the  technique  is  perfect.  Care- 
lessness in  keeping  the  parts  equally  wet  with  salt  solution  or  applying 
the  electrodes  to  different  places  on  the  two  sides  (i.  e.,  a  favorable 
location  on  one  side  and  an  unfavorable  location  on  the  other)  or  mal- 
observation  of  the  eye  movements  during  the  examination  may  lead  to 
failure  to  recognize  the  accurate  balance  noted  above.  However,  ex- 
perience and  earnestness  should  soon  teach  one  the  importance  of  care- 
fulness. 

That  normal  people  show  no  spontaneous  nystagmus  when  looking 
straight  ahead  and  that  they  should  manifest  nystagmus  to  the  oppo- 
site side  when  the  anode  is  used  proves  that  there  must  be  normally  a 
definite  amount  of  bilateral  tension  or  tonus  on  the  two  sides.  This  is 
located  in  the  nerves  and,  in  a  measure,  their  terminals  in  their  end- 
organ  (special  sense  epithelia  in  the  ampullae  of  the  semicircular 
canals).  This  same  tonus  is  present  in  all  nerves  thruout  the  organ- 
ism. It  may  vary  somewhat  in  degree  in  different  individuals  but  is 
ever  present  in  every  healthy  individual.  In  the  case  of  the  vestibular 


i68  GALVANIC  NYSTAGMUS. 

nerve  and  its  endorgan  this  tonus  is  capable  of  accurate  measurement 
and  is  found  to  be  somewhere  between  4  and  8  ma. ;  which  is  the  in- 
tensity of  current  required  to  upset  the  balance  between  the  two  oppo- 
site or  antagonistic  nerves. 

In  pathologic  cases  we  find  a  variety  of  deviations  from 
the  normal  reactions.  The  writer,  after  making  careful  observations 
with  the  galvanic  current  upon  a  great  many  normal  and  pathologic 
cases,  was  able  by  this  method  of  examination  to  divide  the  pathologic 
cases  into  three  primary  groups,  namely : 

I.  Those  with  a  pathologically  over-irritable  inner  ear  of  one  side. 

II.  Those  with  a  pathologically  under-irritable  inner  ear  (destroyed 
inner  ear)   of  one  side  but  with  the  nerve  still  irritable.     The  case 
examined  by  Neumann,   where  after  extirpation  of  the  labyrinth  he 
found  the  nerve  stem  still  reactive  to  the  cathode,  comes  under  this 
group. 

III.  Those  with  negative  irritability  of  both  inner  ear  and  nerve. 
The  pigeons  examined  by  Ewald  after  total  extirpation  of  the  semi- 
circular canals  fall  under  this  group. 

This  same  classification  of  pathologic  conditions  is  possible  in  a 
measure  also  with  the  turning  method  of  examination.  Details  of  the 
individual  cases  examined  by  the  writer  may  be  found  in  a  former 
paper  by  the  writer  ("Klinischen  Studien  ueber  die  Functionsprue- 
fung  des  Labyrinthes  mittles  des  galvanischen  Stromes" — Archir  f. 
Ohrenheilk.,  Bd.  78,  1909). 

There  are  other  secondary  groups,  including  the  cases  of  double 
sided  affections,  etc.,  but  to  cite  them  all  would  only  tend  to  confuse 
the  beginner. 

Let  us  represent  the  normal  reactions  graphically,  as  follows : 

R.  E.  L.  E. 

*K.  4  ma.  Rot.  R.  K.  4  ma.  Rot.  L. 

A.  4  ma.  Rot.  L.  A.  4  ma.  Rot.  R. 


"The  numeral  4  is  here  used  to  show  the  strength  of  current  because  it  is 
approximately  normal  and  can  be  used  to  better  advantage  to  show  what  is  in- 
tended than  the  numeral  5  or  some  other  odd  figure.  We  could  use  quite  as 
'well  the  numeral  6. 

R.  E.  =  right  ear,  L.  E.  =  left  ear,  K.  =  kathode,  A.  =  anode,  Ma. 
=  milliampere,  Rot.  L.  =  rotatory  nystagmus  to  the  patient's  left,  Rot.  R.  — 
rotatory,  nystagmus  to  the  patient's  right. 


LABYRINTH  PAPERS.  169 

If  it  takes  4  ma.  with  the  anode  to  the  right  ear  to  suppress  the  nor- 
mal tonus  sufficiently  to  permit  the  normal  tonus  of  the  left  side  to 
produce  a  rotatory  nystagmus  to  the  left,  \ve  may  conclude  that  the 
strength  of  the  normal  tonus  to  the  right  side  is  equal  to  4  ma.  On 
the  other  hand,  if  4  ma.  with  the  kathode  to  the  right  ear  is  required 
to  produce  rotatory  nystagmus  to  the  right  side,  we  may  conclude  that 
4  ma.  kathodal  irritation  to  the  right  side  plus  the  normal  tonus  of  the 
right  side  is  sufficient  to  overbalance  the  normal  tonus  of  the  left  side. 
In  either  of  the  above  instances  it  is  readily  seen  that  a  difference  of 
4  ma.  tension,  whether  it  be  taken  from  or  added  to  the  normal,  will 
result  in  a  sufficient  overbalance  to  produce  rotatory  nystagmus  to  the 
side  of  the  increase  of  tension  or  to  the  side  opposite  the  diminution. 

I.  A  pathologic  case  with  the  history  of  right-sided  middle  ear 
suppuration  and  attacks  of  vertigo  may  present  the  following  reac- 
tions : — 

R.  E.  L.  E. 

K.  2  ma.  Rot.  R.  K.  6  ma.  Rot.  L. 

A.  6  ma.  Rot.  L.  A.  2  ma.  Rot.  R. 

This  case  shows  first  a  difference  between  the  kathodal  reactions  of 
the  two  sides  of  6  —  2  =  4  ma.,  which  is  just  about  enough  to  produce 
an  overbalance  and  cause  the  subject  to  manifest  a  very  slight  spon- 
taneous nystagmus  to  the  right  side ;  secondly,  a  difference  between 
the  kathodal  and  anodal  reactions  of  the  same  side  of  6  —  2  =  4  ma. ; 
thirdly,  the  kathodal  reaction  of  one  side  just  balances  with  the  anodal 
reaction  of  the  opposite  side,  which  is  just  what  we  find  in  this  group 
of  cases. 

By  comparing  the  figures  in  the  second  case  with  those  in  the  first 
(normal)  we  can  estimate  the  amount  of  pathologic  irritability. 

If  it  takes  normally  4  ma.  with  the  kathode  to  the  right  ear  to  pro- 
duce an  overbalance  of  impulses  to  the  right  side,  then  it  follows,  in 
pathologic  case  I.  where  but  2  ma.  is  required,  that  the  difference 
between  4  ma.  and  2  ma.  or  2  ma.  represents  the  amount  of  pathologic 
irritation  of  the  right  side.  Furthermore,  if  it  takes  4  ma.  with  the 
anode  to  the  right  side  to  suppress  the  normal  tonus,  then  it  follows 
in  this  same  case  where  6  ma.  is  required  that  the  2  additional  ma.  must 
be  used  to  overcome  that  amount  of  pathologic  irritation  of  the  right 
side.  In  the  patient  just  examined  we  may  conclude  that  the  amount 
of  pathologic  irritation  of  the  right  inner  ear  is  equal  to  2  ma.  and 
represent  the  reactions  algebraically  as  follows: 


i7o  GALVANIC  NYSTAGMUS. 

Right  ear: 

R.. \.T.4  ma.  +  R.K.T.  2  ma.  +  R.P.T.2  ma.=  R.T.T.  8  ma. 
R.T.T.  8  ma.  --  L.N.T.  4  ma.  ==  R.B.T.  4  ma.  or  surplus  of  4  ma- 
tension  to  right  side,  which  is  sufficient  to  cause  a  rotatory  nystagmus 
to  the  right  side. 

R.X.T.4  ma.  -f  R.P.T.2  ma  =  R.T.T. 6  ma. 
R.T.T. 6  rna.  —  R.  A.T.6  ma.  +  L.N.T.4  ma.  =  L.B.T.4  ma. 
Since  the  6  ma.  with  anode  to  the  right  side  just  neutralizes  the  -f-  6 
ma.  total  tension  on  right  side,  there  is  left  4  ma.  of  normal  tension 
on  the  left  side  to  produce  rotatory  nystagmus  to  the  left. 

Left  ear : 

R.N.T.4ma.  -f  R.P.T.2  ma.  =  R.T.T. 6  ma. 
L.. \.T.4ma.  +  L.K.T.6ma.  =  L.T.T.io  ma. 
L.T.T.ioma. —  R.T.T. 6  ma.  =  L.B.T.4  ma. 
The  left  total  tension  exceeds  the  right  total  tension  by  4  ma.,  which 
is  sufficient  to  cause  rotatory  nystagmus  to  the  left  side. 
R.N.T.4ma.  +  R.P.T.2  ma.  =  R.T.T.  6  ma. 
L.X.T.4  ma.  —  L.A.T.2  ma.  =  L.T.T.2  ma. 
R.T.T. 6  ma.  —  L.T.T.2  ma.  =  R.  B.  T.4  ma. 
which  is  sufficient  to  cause  a  reaction  to  the  right  side. 

II.  A  second  case,  with  the  history  of  chronic  middle  ear  sup- 
puration of  the  right  ear  combined  with  complete  deafness  of  the 
same  ear  and  vertigo  of  recent  date,  associated  with  spontaneous 
rotatory  nystagmus  to  the  left  side,  may  show  the  following  reactions : 

R.  E.  L.  E. 

K.  7  ma.  Rot.  R.  K.  i  ma.  Rot.  L. 

A.  i  ma.  Rot.  L.  A.  7  ma.  Rot.  R. 

Comparing  these  figures  with  the  normal  we  find : 


*R.N.T.  =  normal  tension  of  right  side. 
R  K.T.  =  kathodal  tension  to  right  side. 
R.P.T.  =  pathologic  tension  of  right  side. 
R.T.T.  =  total  tension  of  right  side. 
L.N.T.  =  normal  tension  of  left  side. 

R  B.T.  =  balance  of  (tension  to  right  side,  or  right  side  irritation  exceeds 
that  of  left  side  by  4  ma. 

R.A.T.  =  anodal  irritation,  or  minus  tension  of  right  side. 
L.K.T.  =  kathodal  irritation  or  tension  to  left  side. 
L.T.T.  =  total  tension  to  left  side. 

L.A.T.  =  anodal  irritation  or  minus  tension  to  left  side. 
L.B.T.  =  balance  of  tension  to  left  side. 


LABYRIXTH  PAPERS.  171 

(i),  with  the  kathode  to  the  right  ear,  that  to  obtain  a  reaction*  a 
much  stronger  current  is  required ;  in  fact,  7  ma.  —  4  ma.  =  3  ma., 
more  than  normal. 

(2),  with  the  anode  a  proportionately  weaker  current  is  required 
(4  ma.  —  i  ma.  =  3  ma.). 

(3),  with  the  kathode  to  the  left  ear  but  i  ma.  current  strength 
is  required  to  produce  a  reaction  (increase  the  nystagmus  to  the  left), 
which  is  3  ma.  less  than  is  required  normally. 

(4),  with  the  anode  3  ma.  more  than  normal  (4  ma.)  is  required. 

From  these  reactions  it  is  evident  that  though  the  irritability  of  the 
right  side  is  diminished,  it  is  not  entirely  lost.  Furthermore,  that 
since  the  right  inner  ear  has  been  destroyed  (thiu  labyrinth  suppura- 
tion) this  remaining  irritability  must  He  elsewhere  than  in  the  inner 
ear,  no  doubt  in  the  nerve. 

Comparing  the  reactions  of  the  left  side  with  those  of  the  right,  we 
find  the  same  reactions  with  the  same  figures  but  reversed  polarity  or 
with  the  same  polarity  but  with  reversed  figures.  In  other  words,  7  ma. 
kathode  to  the  right  side  will  produce  the  same  reaction  as  7  ma. 
anode  to  the  left.  Again,  i  ma.  anode  to  the  right  side,  will  produce 
the  same  character  and  amount  of  reaction  as  i  ma.  kathode  to  the 
left  ear.  Again,  if  the  kathodal  reaction  is  i  ma.  and  the  anodal  is 
7  ma.  on  one  side,  the  reaction  on  the  opposite  side  would  be  kathodal 
7  ma.  and  anodal  i  ma. 

The  explanation  of  reactions  may  be  found  in  the  following  equaT 
tions.  Representing  the  amount  of  pathologic  destruction  in  the 
right  inner  ear  by  3  ma. 

Right  ear: 

R.N.T.4  ma.  —  tR.P.L.T.3  ma.  +R.K.T.7  ma.  =  R.T.T.8  ma. 
R.T.T.8  ma.  —  L.N.T.4  ma.  =  R.B.T.4  ma. 
which  is  just  sufficient  to  cause  a  rotatory  nystagmus  to  the  right. 


*A  reaction  in  this  class  would  be  indicated  by  a  cessation  of  the  spontane- 
ous nystagmus  to  the  left  or  by  a  reversal  oi  the  direction  of  the  nystagmus. 

A  reaction  in  the  case  of  anode  to  the  right  ear  would  be  indicated  by  a 
perceptible  increase  in  the  nystagmus  to  the  left. 

It  must  not  be  forgotten  that  all  of  my  observations  have  been  made  with 
the  patient  looking  straight  ahead  and  not  to  the  sides  as  has  been  done  by 
many  of  the  other  authors. 

fR.P.L.T.  —  right  pathologic  loss  of  tonus  or  tension  (loss  of  tonus  from 
destruction  of  inner  ear).  , 


i72  GALVANIC  NYSTAGMUS. 

R.X.T.4ma.  —  R.P.L.T.3  ma.  —  R.A.T.*  i  ma.  =  R.T.T.o  ma. 

L.X.T.4ina.  —  R.T.T.oma.  =  L.B.T.4ma. 

which  necessarily  produces  spontaneous  nystagmus  to  the  left. 

Left  ear : 

R.N.T.4ma.  —  R.P.L.T.3  ma.  =R.T.T.i  ma. 
L.X.T.4ma.  +  L.K.T.i  ma.  =  L.T.T.5  ma. 
L.T.T.5  ma.  —  R.T.T.i  ma.  =  L.B.T.4  ma. 
which  must  produce  a  nystagmus  to  the  left. 
R.X.T.  4  ma.  —  R.  P.L.T.  3  ma.  ==  R.T.T.  I  ma. 
L-N.T.  4.  ma.  --  L.A.T.  7  ma.  =  L.  T.T.  --  3  ma. 
R.T.T.i  ma.  —  L.T.T.— 3ma.  =  R.B.T.4ma. 
which  difference  in  tension  is  just  sufficient  to  cause  rotatory  nystag- 
mus to  the  right  side. 

III.,  a  third  case  presenting  the  same  history  as  the  last  but  of 
much  longer  duration  (where  the  attack  of  vertigo  has  probably 
antedated  the  examination  two  or  three  months)  will  show  the  fol- 
lowing reaction : 

R.  E.  L.  E. 

K.  12  ma.  or  more,  no  reaction.     tK.  2  or  3  ma.  Rot.  L. 
A.  12  ma^or  more,  no  reaction.     tA.  12  ma.  or  more,  no  reaction. 

Analysis  of  this  reaction  shows  that  the  right  inner  ear  and  nerve 
cannot  be  made  to  react  to  a  current  strength  of  12  Ma.  and  more 
from  which  it  may  be  safely  concluded  that  the  vestibular  nerve  has 
undergone  complete  secondary  degeneration.  The  normal  tonus  is 
still  present  in  the  left  inner  ear  and  nerve  and  it  can  be  made  to 
react  to  both  the  kathode  and  the  anode ;  however,  by  the  most  com- 
plete anelectrotonus  of  the  left  nerve  a  reaction  to  the  right  cannot 
be  produced. 

In  examining  deaf  mutes  I  found  quite  a  number  who  did  not  react 
to  20  ma.  and  even  30  ma.  Besides,  these  were  not  all  cases  due  ex- 
clusively to  early  meningitis;  for  the  great  majority  in  whom  no  re- 
action was  present  were  due  to  other  causes. 


*R.A.T.  =  anodal  tension,  is  always  a  negative  one  and  must  be  represented 
with  a  minus  sign  in  front  of  it. 

tA  barely  perceptible  spontaneous  nystagmus  to  the  left  of  short  excursions 
and  wide  interva's,  is  increased  to  that  of  longer  excursions  and  closer  intervals. 

tWith  the  anode  the  strongest  currents  cannot  reverse  the  direction  of  the 
nystagmus,  however  they  may  cause  a  cessation  of  the  very  slight  spontaneous 
nystagmus  which  is  present  and  from  this  standpoint  it  might  be  said  that  a 
reaction  is  possible  with  a  current  strength  of  somewhat  less  than  12  Ma. 


LABYRIXTH  PAPERS.  173 

In  a  case  where  the  one  or  the  other  side  cannot  be  made  to  react, 
with  either  the  kathode  or  anode,  using  the  strongest  currents  we  may 
safely  conclude  that  it  is  one  of  primary  or  secondary  destruction  of  the 
vestibular  nerve. 

OPEXIXG    AND     CLOSING     NYSTAGMUS. 

The  examination  of  the  opening  and  closing  nystagmus  is  but  one 
step  further  in  the  examination  than  that  which  has  already  been 
cited.  The  same  apparatus  is  used  as  in  the  previous  method  of  ex- 
amination. Ascertain  by  the  previous  method  the  least  current 
strength  required  to  produce  a  positive  reaction  where  a  positive 
reaction  is  possible. 

For  instance,  in  a  normal  case  with  the  patient  reacting  to  4  or  6 
ma.,  the  reactions  should  balance  and  may  be  recorded  as  follows : 

R.  E.    With  4  to  6  ma.    L.  E. 
*K.C.\.  =     K.O.X.  K.C.X.       :   K.O.N. 

A.C.X.  =  .  VO.X.  A.C.N.  =  A.O.X 

The  explanation  of  this  reaction  is  as  fol'ows :  Kathodal  closing 
nystagmus  is  the  nystagmus  which  is  caused  by  closing  the  current 
with  the  kathode  applied  to  the  ear ;  it  is  rotatory  in  character  and 
is  directed  towards  the  side  of  the  kathode.  With  the  use  of  the 
stronger  currents  the  nystagmus  is  associated  with  the  sensation  of 
falling  in  the  sagittal  plane  towards  the  kathode,  while  actual  (re- 
action) falling  occurs  in  the  opposite  direction,  away  from  the  kathode. 
This  latter  fact  was  pointed  out  long  since  by  numerous  writers,  in- 
cluding Kreidl  and  Alexander. 

Kathodal  opening  nystagmus  is  the  nystagmus  which  occurs  for  a 
few  seconds  after  the  breaking  of  the  current.  It  is  most  intense  at 
the  moment  the  current  is  interrupted.  It  is  rotatory  and  is  directed 
towards  the  opposite  side  (away  from  the  kathode).  With  the 
stronger  currents  it  is  associated  with  the  sensation  of  falling  in  the 
sagittal  plane  away  from  the  kathode,  while  actual  falling  occurs  to- 
wards the  kathode. 


*K  C.N.  =  kathode  closing  nystagmus. 
K.O.N.  =  kathode  opening  nystagmus. 
A.C.N.  =  anode  closing  nystagmus. 
A  O.N.  =  anode  opening  nystagmus. 
>  =  greater  than. 
=  less  than. 


174  GALVANIC  NYSTAGMUS. 

Anodal  closing  nystagmus  is  the  nystagmus  which  is  produced  by 
closing  the  current  with  the  anode  applied  to  the  ear.  It  is  rotatory 
in  character  and  is  directed  towards  the  opposite  side ;  with  the 
stronger  currents  it  is  associated  with  the  sensation  of  falling  in 
the  sagittal  plane  towards  the  opposite  side,  while  actual  falling  oc- 
curs towards  the  same  side. 

Anodal  opening  nystagmus  is  the  nystagmus  which  results  from 
opening  or  breaking  the  current  with  the  anode  applied  to  the  ears 
and  lasts  for  a  few  seconds  but  is  most  intense  at  the  instant  of 
breaking  the  current.  It  is  rotatory  in  character  and  is  directed  to- 
wards the  same  side.  With  the  stronger  currents  it  is  associated 
with  the  sensation  of  falling  in  the  sagittal  plane  towards  the  same 
side  while  the  actual  falling  occurs  towards  the  opposite  side  (away 
from  the  anode). 

In  the  first  type  of  pathologic  case  recorded,  that  is  with  a  path- 
ologically over-irritable  right  inner  ear,  we  find  the  reaction  to  be : 

R.  E.     With  4  to  6  ma.     L.  E. 
K.CN.  >  K.O.N.  K.C.N.    <    K.O.N. 

A.C.N.  <  A.O.N.  A.C.N.    >    A.O.N. 

In  the  second  type  of  case  suffering  with  pathologically  destroyed 
right  inner  ear  but  with  intact  nerve,  we  find  the  reaction  to  be : 

R.  E.     With  4  to  6  ma.     L.  E. 
K.C.N.  <  K.O.N.  K.CN.    >    K.O.N. 

A.C.N.  >  A.O.N.  A.C.N.    <    A.O.N. 

In  the  third  type  of  case  suffering  with  pathologically  destroyed  right 
inner  ear  combined  with  secondary  degeneration  of  the  vestibular 
nerve,  we  find  the  reaction  to  be : 

With  current  strength  of  12  ma.  or  more. 

R.  E.  L.  E. 

K.CN.  and  K.O.N.  not  present.        K.CN.     >     K.O.N. 
A.C.N.  and  A.O.N.  not  present.        A.C.N.     <     A.O.N. 
Strictly  speaking  there  is  no  K.O.N.  or  A.C.N.  upon  the  left  side 
in  this  group  of  cases.     The  most  that  may  be  expected  by  opening 
the  current  with  the  kathode  or  closing  it  with  the  anode  is  the  ces- 
sation of  the  existing  nystagmus  to  the  left  side,  which  we  may  ac- 
cept as  a  positive  galvanic  reaction.     The  production  of  a  nystagmus 
to  the  right  side,  however,  in  the  case  of  destroyed  vestibular  nerve 
of  the  right  side  is  impossible  by  any  method  of  irritation  of  the 
destroyed  nerve  or  inhibition  of  the  opposite  nerve. 


yr 
j 
V 


UTRICULUS  AND  SACCULUS. 

THE   utriculus   and    sacculus    are    the   two   membranous    sacs 
located  within  that  part  of  the  osseous  labyrinth  known  as 
the  vestibule.     The  utriculus  is  located  just  anteriorly  to 
the   semicircular  canals   and  is  in   direct  communication   with   them 
through   five   openings.     'The   sacculus   is   located   anteriorly   to   the 
utriculus  and  posteriorly  to  the  ductus  cochlearis  and  is  in  direct  com- 
munication  with  the  latter  through  the  ductus  reuniens.    The  utriculus 
and  sacculus  are  in  communication  with  each  other  through  the  ductus 
utriculo-saccularis.  ) 

(The  utriculus  and  sacculus  each  contain  an  endorgan  known  as  a 

Nniacula  acustica.  composed  of  a  group  of  ciliated  neuro-epithelia  with 

alternating  supporting  cells.    The  cilia  of  the  neuro-epithelia  are  short. 

The  maculse  are  somewhat  elliptical  in  shape  with  the  long  axes 
running  at  right  angles  to  each  other.  On  the  surface  of  each  macula 
is  a  jelly-like  mass  in  which  is  suspended  small  calcium  carbonate 
crystals  (otoliths  or  statoliths).") 

(These  sacs  are  phylogenetically  the  oldest  part  of  the  ear  labyrinths; 
the  simplest  form  of  which  is  that  found  in  the  Ctenophores~)(jelly 
fish)  for  which  Yerworm,  because  of  its  function,  suggested  the  name 
statocyst.  That  these  sacs  perform  a  function  distinctly  separate 
from  that  of  the  semicircular  canals  has  been  shown  by  the  researches 
of  Delage,  Yerworm.  Breuer.  Mack,  Engelman,  Kreidl,  Lee,  Kubo 
and  others. 

|\\s  early  as  1874  Mack1  expressed  the  view  that  the  sensation  of 
angle  accelerations  (turnings)  is  mediated  probably  thru  the  three 
semicircular  canals  and  that  of  progressive  movements  presumptively 
thru  the  sacculusj  "Die  Empfindungen  der  drei  Winkelbeschleunig- 
ungen  werder  wahrscheinlich  durch  die  Ampullennerven  der  drei 
Bogengaenge  die  Empfindungen  der  Progressivbewegungen  muth- 
masslich  durch  den  Sacculus  vermittelt." 

Breuer2  simultaneously  expressed  the  same  view  and,  too,  he  be- 
lieved that  reflex  contrarolling  movements  of  the  eyes,  "reflectorischen 
Stellungsveraenderungen  der  bulbi,"  (observed  also  by  Graefe8, 
Skrebitzky4  and  Xagel5)  which  are  manifested  by  changes  of  posi- 
tion of  the  head  are  produced  reflexly  from  the  ear  labyrinth  —  macula 


176  UTRICULUS  AND  SACCULUS. 

acustica  and  the  otolithic  mass.  To  Breuer,  these  reflex  contrarolling 
move  rents  of  the  eyes  were  an  argument  in  favor  of  the  supposed 
function  of  the  macula  acustica  and  otolithic  mass  as  expressed  by 
himself  and  Mach.  We  shall  refer  to  Breuer  again  later. 

Carl  Chun6,  in  1880,  experimented  upon  the  ctenophores  in  the 
Gulf  of  Naples ;  he  held  the  opinion  that  the  otocyst  in  the  inverte- 
brates probably  performed  an  equilibrium  function. 
V  Henry  Sewall7  experimented  upon  the  ears  of  fishes  (young  sharks 
and  skates)  at  the  marine  laboratory  of  the  Johns  Hopkins  University 
at  Beaufort,  N.  C,  in  1881,  and  on  the  Chesapeake  Bay  in  1883.)  He 
claimed  theories  essentially  similar  to  Goltz,  Crum-Brown  and  Breuer, 
that  the  endolymph  within  the  membranous  labyrinth  presses  with 
every  new  movement  of  the  head  with  greater  or  less  force  upon  the 
auditory  nerve  endings  within  definite  ampullae  of  the  canals  and  thus 
mechanically  stimulates  them.f  He  also  attempted  the  removal  of  the 
otoliths  from  the  \nesrrh»l3^acs?^  In  some  cases  he  was  able  to  pro- 
duce equilibrium  disturbances,  while  in  others  he  failed.  J  Although 
his  experiments  were  ingenious,  on  the  whole  they  led  him  rather  to 
uncertainty  than  to  any  definite  conclusions. 

W.  James8,  of  Harvard  University,  in  1887,  found  that  of  200 
normal  people  who  were  subjected  to  turning  but  one  only  was  free  of 
vertigo,  whereas  of  517  deaf  mutes  subjected  to  the  same  turning, 
1 86  had  absolutely  no  vertigo.  He  learned  further  from  many  of  these 
(186),  that  when  they  were  under  water  they  suffered  an  indescrib- 
able confusion  and  anxiety  which  was  relieved  only  when  the  head 
came  above  the  surface.  Similar  experiments  subsequently  conducted 
by  others,  and  particularly  Breuer,  corroborated  the  observations  of 
James.  Nothing  could  be  more  conclusive  to  show  that  the  ear  con- 
tains an  organ  for  orientation  in  space  which,  when  lost,  materially 
handicaps  the  subject.  Furthermore  that  the  eyes  are  capable  in  a 
ireasure  of  overcoming  the  loss  of  equilibrium  which  results  from  a 
complete  destruction  of  the  ears. 

Yves  Delage9  in  1886  conducted  a  series  of  interesting  experi- 
ments upon  cephalopods  and  crustaceans.  Among  other  experiments 
he  removed  the  otocysts  from  a  crab  and  found  that  the  animal  was 
but  slightly  disturbed  during  the  act  of  crawling,  but  during  attempts 
at  swimming  the  crab  made  all  sorts  of  irregular  movements.  He  then 
blindfolded  the  animal  and  found  the  disturbances  still  more  pro- 


LABYRINTH  PAPERS.  177 

nounced ;  whereas  normal  crabs  blindfolded  made  the  same  regular 
move-rents  but  somewhat  slower  and  more  cautiously  than  when 
the  eyes  were  not  blindfolded.  He  repeated  these  experiments  on 
other  forms  of  crustaceans.  The  results  of  his  experiments  proved  to 
him  that  the  otocyst  is  an  organ  for  orientation  in  space  while  the 
eyes  and  the  antennae  (feelers)  are  capable  of  correcting,  in  a  measure, 
for  such  loss  of  orientation  which  results  from  the  loss  of  the  otocysts. 

The  work  of  Delage  prompted  T.  H.  Engelmann10  to  publish  an 
article  wherein  he  cites  his  own  observations  made  several  years  be- 
fore, upon  the  otoliths  of  the  ctenophores.  Engelmann  held  that  the 
otolith  and  the  sac  which  holds  it  perform  a  function  of  body  equilib- 
rium— "den  allgemein  als  Otolithen  bezeichneten,  am  aboralen  Pol 
cles  Ctenophorenkoerpers  gelegenen  Kalkkoerper  fuer  einen  die  Ert 
haltung  des  Koerpergleichgewichts  vermittelunden  Apparat." 

Max  Yerworm's11  experiments  upon  the  ctenophores  (euchris 
rrulticornis,  bolina  hydatina,  beroea  ovata)  led  him  to  conclude  that  the 
otolith  and  otocyst  performed  the  function  of  equilibrium  in  these 
animals,  endorsing  the  prior  supposition  of  Engelmann.  Because  of 
their  function  he  suggested  the  terms  statolith  and  statocysts  as  more 
appropriate  than  otolith  and  otocyst.  He  experimented  further  with 
these  animals  to  determine  if  possible  whether  these  organs  performed 
in  addition  an  acoustic  function.  He  failed,  as  did  also  Chun,  to  pro- 
duce any  response  to  the  loudest  tones  and  noises. 

Jacques  Loeb12  experimented  upon  sharks  (scyllium  canicula  and 
catalus)  in  the  winter  of  1890x91  at  the  Zoological  Station  at  Naples, 
resecting  certain  parts  of  the  brain  (the  cerebral  hemispheres,  the 
middle  brain,  the  medulla  oblongata  in  the  region  of  the  eighth  nerve 
and  the  eighth  nerve).  He  found  as  the  result  of  section  of  the  eighth 
nerve,  forced  movements  of- the  eyes  to  the  destroyed  side  and  the  mem- 
bers (fins)  to  the  opposite  side,  together  with  rolling  movements  and 
circus  movements  (around  a  ring)  towards  the  operated  side  during 
attempts  of  the  animals  to  make  voluntary  movements. 

Loeb  in  a  separate  article  (Geotropismus  bie  Thieren)  recites  his  ex- 
periments upon  the  inner  ears  of  the  sharks.  When  the  otoliths  of  one 
side  were  removed,  he  found  the  animals  deviated  laterally  down- 
ward to  the  operated  side  from  20°  to  50°.  When  the  otoliths  of  both 
sides  were  removed  the  animals  failed  to  retain  the  normal  horizontal 
position  of  equilibrium  even  when  they  were  so  placed.  These  operated 
12 


178  UTRICULUS  AND  SACCULUS. 

animals  furthermore  failed  to  show  the  normal  forced  (reflex)  move- 
ments of  the  eyes  (contrarolling  movements)  manifested  by  changes  of 
position. 

Kreidl13  likewise  observed  this  lack  of  balance  in  sharks  with  double 
side  loss  of  otoliths ;  he  found  that  the  sharks  would  as  frequently 
swim  or  lie  on  their  backs  as  they  would  take  any  other  position. 

F.  S.  Lee14  in  1893  conducted  experiments  mostly  upon  dog  sharks 
galens  cam's)  and  some  five  specimens  of  skates  (raja  erinacea).  In 
his  introduction  he  claims  that  "a  complete  theory  of  the  socalled 
'equilibrium'  function  of  the  internal  ear  ought  to  be  competent  to 
explain  three  classes  of  facts,  viz.,  the  equilibrium  phenomena  of  the 
resting  body,  those  of  the  body  moving  in  a  straight  line,  and  those  of 
the  body  moving  in  a  curve.  The  first  comprises  the  statical,  the  last 
two  dynamical  phenomena." 

He  points  out  the  fact  that  birds  and  fishes  are  naturally  best  adapted 
for  study  because  these  animals  spend  so  much  of  their  time  in  a  fluid 
medium  out  of  contact  with  a  solid  supporting  surface. 

Lee  noted  compensatory  eye  and  fin  movements.  He  endorses 
Breuer's  work  and  conclusions  and  sums  up  under  the  heading, 
"Equilibrium  Function  of  the  Ear." 

"ll.       STATIC    FUNCTIONS. 

"(a)  Normal:  Sensations  of  position  of  the  body  in  space  accom- 
panying corresponding  positions  of  the  eyes  and  fins  ;  varying  according 
to  nerve  stimulated  (  ?). 

"(b)  Pathological:  Abnormal  sensation  causing  lack  of  orienta- 
tion and  abnormal  position  of  the  eyes,  fins  and  trunk ;  varying  accord- 
ing to  the  nerve  thrown  out  of  function.  (Localization  of  statical  func- 
tion in  otolithic  parts;  stimulation  continual.) 

Breuer15  in  1891  in  an  hiteresting  article  on  the  subject  of  the 
functions  of  the  otolithic  apparatus,  reviews  the  literature  up  to  that 
time,  and  sets  forth  his  own  theories  as  to  the  subject.  Quoting  as  ac- 
curately as  I  can  from  his  resume: 

"RESUME,  PAGE  268. 

"i.     There  exists  positively  specific  sensations  for  the  position  of  the 
head  to  the  vertical  and.  for  progressive  (straight  line)  movements. 
"2.     The  topographic  arrangement  of  the  otolithic  apparatus  makes 


LABYRIXTH  PAPERS.  179 

it  most  probable  that  they,  like  the  semicircular  canals,  have  to  do  with 
the  perception  of  local  or  spacial  conditions.  Their  structure  makes  it 
probable  that  the  gravitation  of  the  otoliths  is  the  producing  irritant. 

"3.  The  Ausf allserscheinungen  ( i.  e.,  the  phenomena  resulting  from 
the  loss  of  function)  in  frogs  and  birds  with  destroyed  labyrinths  and 
of  deaf  mutes,  proves  that  the  labyrinth  mediates  the  perception  of 
position  in  space,  which  in  the  cases  cited  (deaf  mutes)  were  com- 
pletely absent,  when  by  immersing  under  water  they  who  were  form- 
erly orientated  lost  for  the  most  part  their  sensations  of  gravitation. 

"4.  Every  position  of  the  head  corresponds  in  man  to  a  definite 
combination  of  gravitations  upon  the  four  maculae.  When  we  accept 
that  gravitation  of  the  otolithic  plates  drags  on  the  cilia  and  excites 
nerve  endings,  producing  an  irritation  which  is  conveyed  to  the  center 
for  the  conception  of  position,  then  it  appears  that  the  sacs  of  the 
labyrinth  are  (collectively)  an  organ  entirely  adapted  as  one  of  special 
sense  for  the  perception  of  our  location  in  space." 

I  might  go  on  page  after  page  reviewing  the  experiments  and  pub- 
lications of  Kreidl13,  Crum-Brown16,  Bunting17,  Bethe18,  Rawitz", 
Lautenback20,  Alexander  and  Kreidl21,  Cyon".  Panse28,  Ach2*, 
Zoth25,  Froelich26,  and  others,  but  instead  I  will  proceed  directly  to  a 
brief  discussion  of  what  may  be  considered  the  most  important  and 
conclusive  work  accomplished  in  this  direction  (the  physiology  of  the 
vestibular  sacs).  I  refer  to  that  done  by  Ino  Kubo37. 

The  experimental  research  work  of  Kubo  is  the  most  exact  and  thoro 
of  its  kind.  He  spent  the  winter  of  1905  and  1906  at  the  K.  K. 
Zoological  Station  in  Triest  experimenting  on  living  fish  (scyllium 
canicula,  acanthias  vulgaris,  mustelus  laevis,  rhombus  maximus,  pleuro- 
noctes  platessa,  raja  clarata,  torpedo  marmorata  and  petromyzon 
marinus). 

1.  His  experiments  consisted  of  studying  the  eye  movements  during 
active  and  passive  turnings  of  the  animals. 

2.  Experiments  upon  the  semicircular  canals  and  the  ampullae  by 

(a)  Thermic  irritation. 

(b)  Mechanical  irritation. 

(c)  Galvanic  irritation. 

3.  He  studied  the  deviations  of  the  eyes  when  the  animals  were 
passively  turned  to  different  positions  and  made  experiments  on  the 
otoliths  of  the  vestibular  sacs  (utriculus,  sacculus  and  legena). 


i8o  UTRICULUS  AND  SACCULUS. 

It  is  that  part  of  Kubo's  research  which  dealt  with  a  study  of  devia- 
tions of  the  eyes  and  experiments  upon  the  sacs  which  interests  us 
more  especially  at  present. 

The  exactness  of  Kubo's  methods  and  the  logic  of  his  conclusions 
practically  preclude  any  adverse  discussion;  I  shall  therefore  briefly 
outline  his  work.  For  various  reasons  some  of  tKe  fish  were  better 
adapted  for  one  form  of  study  than  others  and  vice  versa ;  so  that  I 
shall  recite  the  results  obtained  generally  rather  than  those  obtained  in 
each  individual  fish. 

EVE  POSITIONS  (DEVIATIONS). 

When  the  fish  was  held  in  the  position  of  long  axis  horizontally  and 
with  the  belly  down,  the  eyes  assumed  their  normal  position. 

When  the  fish  was  turned  to  the  vertical  position,  head  up,  the  eyes 
rolled  downward  and  remained  there  as  long  as  the  fish  was  held  in 
that  position. 

When  the  fish  was  turned  to  the  vertical  position,  head  down,  the 
eyes  rolled  upward  and  remained  there  as  long  as  the  fish  was  held  in 
that  position. 

When  the  fish  was  turned  to  the  horizontal  position  with  the  belly 
up  the  eyes  resumed  the  primary  position  as  in  the  case  of  belly  down. 

In  the  side  position  (with  long  axis  horizontal)  the  eyes  deviated  in 
the  vertical  axis,  so  that  the  upper  eye  deviated  downward  and  the 
under  eye  upward. 

To  show  that  these  deviations  of  the  eyes  were  not  dependent  upon 
the  semicircular  canals  Kubo  then  removed  the  membranous  canals 
together  with  their  ampullae,  when  he  found  that  the  identical  devia- 
tions of  the  eyes  occurred  as  in  the  first  instance.  He  next  removed 
the  sacs  of  both  sides,  when  he  found  the  deviations  ceased  to  occur. 

When  the  sacs  of  one  side  only  were  removed  the  deviation  occurred, 
but  not  so  pronounced  as  when  both  sides  were  intact. 

KUBO'S   EXPERIMENTS   ON    OTOLITHS. 

i.  He  exposed  the  membranous  sacs  to  full  view  and  observed  the 
gliding  movements  of  the  otoliths. 

When  changing  the  position  of  the  fish  from  the  horizontal  (belly 
down)  to  the  vertical,  head  up,  he  was  able  to  see  plainly  a  gliding 
movement  of  the  otoliths  of  the  sacculus  downward.  In  the  side  posi- 
tions the  movement  of  the  otoliths  in  the  sacculus  was  slight  but  visible. 


LABYRINTH  PAPERS.  181 

Briefly,  he  found  the  otolithic  mass  to  glide  or  gravitate  in  a  direction 
corresponding  to  the  movement  of  the  eyes  or  contrary  to  the  move- 
ment of  the  head. 

2.  Direct  manipulation  of  the  otoliths  with  small  cotton  protected 
probes. 

When  the  otolithic  mass  was  pushed  with  the  probe  in  definite  direc- 
tions the  eyes  deviated  in  the  corresponding  directions.  For  instance, 
when  the  otoliths  of  utriculus  (fish  in  the  horizontal  position,  belly 
down)  were  gently  shoved  forward  the  eyes  would  deviate  upward,  the 
position  corresponding  to  that  which  occurs  when  the  head  is  turned 
downward  and  the  otolith  mass  of  the  utriculus  naturally  gravitates 
forward. 

A-ain,  when  otoliths  of  the  sacculus  were  gently  shoved  backward 
the  eyes  deviated  downward ;  the  position  corresponding  to  that  which 
occurs  when  the  head  is  turned  upward. 

liriefly,  every  artificial  movement  of  the  otoliths  produced  reflex 
deviations  of  the  eyes  corresponding  to  those  produced  by  the  same 
natural  movements  of  the  otoliths  which  follow  changes  in  position  of 
the  head. 

3.  Experiments  after  partial  or  total  extirpation  of  the  otoliths. 
After  the  removal  of  the  otoliths  of  the  sacculus  the  rotation  of  the 

eyes  by  the  position  head  up  was  very  indistinct,  while  the  rotation  of 
the  eyes  by  the  position  head  down  was  quite  distinct ;  from  which  he 
concluded  that  the  rolling  of  the  eyes  in  the  position  of  the  head  down 
was  due  principally  to  the  forward  gliding  of  the  otoliths  in  the 
utriculus. 

After  the  removal  of  the  otoliths  of  the  utriculus  from  one  side  the 
deviations  of  the  eyes  by  the  position  head  up  and  head  down  was 
very  indistinct.  After  the  removal  of  all  otoliths  from  one  side  the 
deviations  of  the  eyes  by  the  position  of  the  head  up  and  head  down 
occurs  but  slightly  on  the  unoperated  side  only.  In  the  side  positions 
also  only  on  the  unoperated  side. 

By  turning  the  fish  in  the  horizontal  plane  after  total  extirpation  of 
the  otoliths  of  one  side  there  occurs  no  deviation  bulbi  horizontalis  by 
turning  towards  the  operated  side,  while  turning  toward  the  healthy 
side  produces  distinct  deviation  hulbi  bilateralis  and  in  this  case  the 
deviation  is  stronger  in  the  eye  corresponding  to  the  unoperated  side. 

4.  Electrical  irritation  of  the  nerve  branches  after  the  removal  of 
the  otoliths  together  u'ith  the  ampulla:. 


:82  UTRICULUS  AND  SACCULUS. 

As  previously  observed,  one  sees  two  groups  of  nerve  fibres  in  the 
floor  of  the  utriculus  and  one  group  in  the  sacculus.  From  the  anterior 
group  branches  go  to  the  macula  utricularis  and  to  the  two  ampullae 
(anterior  and  horizontal)  and  from  the  posterior  group  branches  go 
to  the  macula  saccularis  and  the  ampullae  of  the  posterior  canal.  Kubo 
observes  that  one  cannot  irritate  the  individual  nerve  fibers  of  each 
group ;  however,  he  was  able  to,  at  least,  irritate  separately  the  three 
groups  of  fibers,  the  results  of  which  follow : 

i.  By  electrical  irritation  of  the  nerve  fiber  group  to  the  utriculus 
of  one  side,  the  nasal  pole  of  both  eyes  turned  upward  corresponding 
to  the  position  of  the  head  down. 

By  electrical  irritation  of  group  III  (the  group  of  fibers  to  the 
utriculus)  the  eyes  of  both  sides  deviated  horizontally  to  the  side  oppo- 
site the  irritation,  corresponding  to  that  which  appears  by  turning  of 
the  head  to  the  operated  side. 

By  electrical  irritation  of  group  III  (the  group  of  fibers  of  the 
sacculus)  the  nasal  pole  of  both  eyes  deviated  downward,  correspond- 
ing to  the  position  of  head  up. 

When  the  contents  of  the  vestibulum  were  curetted  entirely  away 
and  the  remaining  nerve  stem  was  electrically  irritated,  the  eyes  rolled 
in  the  horizontal  plane  as  in  the  case  of  rabbits  and  pigeons. 

CONCLUSION. 

Among  other  things  Kubo  observed  that  "also  with  fish  every  body 
position  corresponds  to  an  exact  eye  position  and  when  the  otoliths 
are  removed  or  the  entire  vestibular  apparatus  is  destroyed  this  re- 
lationship is  lost."  He  then  cites  a  list  of  authors  who  had  since  the 
time  of  Hunter27  observed  and  studied  these  eye  movements  (con- 
trarolling)  which  occur  as  the  result  of  inclinations  of  the  head.  He 
gives  credit  to  Mack  and  Breuer  as  the  first  authors  to  point  out 
separate  functions  for  the  semicircular  canals  and  for  the  otolithic 
apparatus.  "The  single  direct  proof  until  now  (of  the  functions  of 
the  otolithic  apparatus)  was  Kreidl's  iron  filing  experiments  upon 
crabs." 

"Die  Verschiebung  oder  Gleitung  der  Otoliten  ist  wenigstens  bei 
Rochen  und  Acanthias  vulgaris  bei  Lagewechsel  des  Korpers  sicher 
zu  konstatieren ;  und  die  kuensiliche  Verschiebung  der  Otoliten  hat 
dieselbe  Bulbusdrehung  zur  Folge  wie  der  Lagewechsel  des  Koerpers 
—wenigstens  fuer  die  Lagen  'Kopf  oben  und  Kopf  unten.'  Das  ist 


LABYRINTH  PAPERS.  183 

ein  neuerlicher  Beweis  class  die  Gleitung  der  Otoliten  die  Xervenend- 
igungen  reizt,  wie  dies  Breuer  annimmt.  Aus  den  Yersuchsresultaten 
geht  hervor,  dass  der  Zug  odor  die  Spannung  der  Haarzellen  durch 
die  Gleitung  der  Otoliten  als  normaler  Reiz  zu  betrachten  ist.  Je 
nach  der  Gleitrichtung  muessen  die  verschiedenen  Xervenendzweige 
gereizt  werden,  deren  reflektorische  Funktionen  (oder  Verbindungen) 
ungefaehr  durch  elektrische  Reizung  zu  bestimmen  sind ;  Z.  B.  in  der 
'Lage  Kopf  unten'  muss  der  Otolit  des  Utriculus  nach  vorn  gleiten 
und  diejenigen  Xervenzweige  reizen,  die  durch  elektrische  Reizung 
in  der  Bauchlage  die  Bulbi  so  zu  drehen  veranlassen.  dass  der  nasale 
Bulbuspol  nach  oben  geht  ('I.  Gruppe')  ;  diese  Xervenzweige  treten 
zur  Macula  utriculi  in  Beziehung.  In  der  Lage  'Kopf  oben'  gleiten 
die  beiden  Otoliten  des  Sacculus  und  Utriculus  kaudalwarts.  allein 
der  Otolit  des  Sacculus  uebt  den  wirksamen  Zug  auf  die  Haarzellen 
der  Macula  sacculi  aus,  wie  die  kuenstliche  Verschiebung  des  sac- 
cularen  Otolits  und  die  elektrische  Reizung  der  Xervenzweige  im 
Sacculus  ('III.  Gruppe')  uebereinstimmend  gezeigt  haben.  Fuer  die 
Deviatio  bulbi  bilateralis  horizontalis  kommt  die  II.  Gruppe  in 
Betracht;  es  ist  jedoch  schwierig,  in  diesem  Falle  die  horizontale  Am- 
pulle  auszuschalten,  die  selbst  von  der  II.  Gruppe  die  Nerven- 
endzweige  aufnimmt.  Die  Bulbusstellungen  in  den  Seitenlagen 
kcennten  von  der  kombinierten  Wirkung  der  beiden  Otoliten  (des 
Utriculus  und  Sacculus)  herruehren. 

Die  Macula  lagenae  entzieht  sich  bei  Fischen  dem  Experiment ;  bei 
der  von  Breuer  festgestellten  Tatsache,  dass  die  drei  Otoliten  in  den 
drei  Dimensionen  des  Raumes  orientirt  sind,  wird  man  anzunehmen 
das  Recht  haben,  dass  diese  Apparate  zur  Wahrnemung  der  Kopf — 
bz\v.  Koerperlage  dienen.  Die  Reizung  der  maculae  durch  die  Gleit- 
ung der  Otoliten  ruft  reflekttorisch  die  eigentuemlichen  Bulbusstel- 
lungen hervor. 

\Yie  Lee  beschreibt,  ist  die  Deviatio  bulbi  bilateralis  horizontalis 
beim  Drehen  des  Tierkoerpers  in  der  Horizontalebene  vergaenglich 
temporaer  aber  man  hat  kein  Recht,  deswegen  nur  dem  horizontalen 
Bogengang  (resp.  seiner  Ampulle)  eine  besondere  dynamische  Funk- 
tion  (d.h.  die  Wahrnehmung  der  Kreisbewegung)  zuzuschreiben ; 
denn  meine  Versuche  haben  gezeigt,  dass  bei  Drehung  des  Tierkoer- 
pers in  der  Seitenlage  oder  in  der  lage  'Kopf  oben'  oder  'unten' 
eben  falls  Deviationen  der  Bulbi  von  verganglichen  Xatur  auftreten. 
Man  wird  annehmen  muessen,  dass  beim  Drehen  die  Bogengaenge 


184  UTRICULUS  AND  SACCULUS. 

(mit  ihren  Ampullen)  mit  dem  Otolitenapparate  stets  gemeinsam  in 
Taetigkeit  versetzt  werden,  vvobei  die  Bogengaenge  fuer  die  \Yahr- 
nehmung  der  \\"inkelbeschleunigung  und  die  Otolitenapparate  fuer  die 
\\  ahrnehmung  der  Lage  (wahrscheinlich  auch  der  geradlinigen  Be- 
wegung)  bestimmt  sind. 

RESUME. 

Paragraphs  i,  2,  3,  5  and  6  concern  more  the  subject  of  eye  move- 
ments associated  with  the  physiology  of  the  semicircular  canals ;  the 
remaining  paragraphs  given  below  pertain  more  to  that  of  the  sacs. 

4.  The  positions  of  the  eyes  are  definite  for  every  body  position,  as 
in  the  case  of  rabbits. 

7.  The  maximal  deviation  of  the  bulbus    (especially   in  the  side 
position)  goes  back  considerably  after  a  short  time. 

8.  After  the  extirpation  of  the  semicircular  canals  there  still  occurs 
these  same  altered  eye  positions  (contrarolling)  always  according  to 
the  definite  body  positions.     They  diminish  perceptibly  after  the  re- 
moval of  the  otoliths  of  one  side  and  disappear  altogether  after  the 
complete  removal  of  the  otoliths  of  both  sides. 

9.  The  gliding  movements  of  the  otoliths  are  actually  visible  by 
change  of  position  of  the  body  in  Rochen  and  Acanthias.     Gliding  of 
the  otoliths  artificially  produced   (while  the  animal  is  in  the  normal 
horizontal  position  with  belly  down)   produces  the  same  eye  move- 
ments which  occur  from  the  natural  gliding  movements  of  the  otoliths. 

10.  Each  group  of  nerve  endings  in  the  vestibulum  reacts,  after  the 
removal  of  the  otoliths,  to  electric  irritation  with  a  definite  eye  move- 
ment. 

11.  The  alterations  of  eye  position  with  changes  of  body  position 
are  produced  reflexly  by  a  gliding  movement  of  the  otoliths  (at  least) 
from  the  macula  utriculi  and  sacculi. 

Clinical  observations  of  contrarolling  movements  of  the  eyes  in  man 
have  been  made  by  Barany28.  He  had  a  specially  designed  instrument 
constructed  by  Schwartz,  of  Vienna,  for  the  accurate  measurement  of 
the  normal  contrarolling  movements,  which  had  been  observed  by  many 
others  (see  above),  and  that  these  are  perceptibly  diminished  in  cases  of 
one  sided  labyrinth  destruction,  however  he  has  not  written  much 
upon  the  subject.  It  is  to  be  hoped  that  he  will  sooner  or  later  give  us 
an  extensive  report  of  his  investigations  along  this  line. 

The  writer29  examined  clinically  the  following  character  of  cases — 


LABYRINTH  PAPERS.  185 

(i)  Those  with  one  sided  labyrinth  destruction,  (2)  those  with  double 
sided  labyrinth  destruction  (selected  deaf  mutes),  and  (3)  those  with 
labyrinth  diseases  showing  an  increased  reactibility  of  the  vestibular 
apparatus — for  the  purpose  of  ascertaining  to  what  degree  equilibrium 
is  dependent  upon  the  semicircular  canals  and  the  vestibular  sacs.  Sim- 
ilar efforts  had  been  previously  attempted  by  Frey  and  Hammer- 
schlag30,  Krotoscheiner31,  Kummels32,  Von  Stein33,  Pollack34,  Kreidl35, 
Alexander  and  MacKenzie30,  and  others  whose  experiments  had  been 
made  principally  upon  deaf  mutes.  The  writer's  own  clinical  examina- 
tions differ  in  some  particulars  from  those  attempted  by  previous  in- 
vestigators. 

First  of  all  patients  showing  the  least  evidence  of  hysteria,  neuras- 
thenia, syphilitic  cerebral  or  spinal  affections,  visual  defects,  natural 
clumsiness  or  poor  intelligence  were  excluded  from  the  list.  (2)  To 
ascertain  these  facts  the  history  of  the  patient  was  most  carefully  taken, 
the  vision  determined,  and  in  some  cases  the  eyegrounds  examined. 
The  pupillary  and  deep  reflexes  were  examined  as  also  coordination. 

\Yhen  we  consider  that  equilibrium  may  be  disturbed  by  a  lesion  of 
any  one  of  the  three  peripheral  sense  organs  of  orientation  (eyes, 
vestibular  apparatus,  kinesthetic  sense  organs,  in  the  deep  muscles, 
joints,  etc.)  or  their  centripetal  tracts  to  their  terminals  in  the  brain,  we 
appreciate  how  important  it  is.  in  making  these  clinical  investigations, 
to  include  an  examination  of  vision,  pupillary  and  tendon  reflexes. 

Furthermore,  since  the  examinations  to  be  made  were  rather  ex- 
haustive, it  was  necessary  to  select  intelligent  patients,  free  from  any 
acute  ailments  that  might  in  any  way  tend  to  hasten  fatigue. 

\-ain.  it  was  necessary  to  examine  the  patients  with  one  sided 
labyrinth  destruction  at  a  period  sufficiently  remote  from  the  acute 
affection  to  avoid  confusing  the  acute  equilibrium  disturbances  with 
those  which  I  have  termed  the  late. 

The  condition  of  the  labyrinth  was  determined  by  the  usual  func- 
tional examination  methods  as  practiced  in  Professor  Alexander's 
clinic.  I  was  doubly  certain  of  most  of  the  cases  of  one  sided  labyrinth 
destruction  from  the  fact  that  they  had  previously  undergone  the  opera- 
tion for  its  removal. 

The  equilibrium  was  determined  by  the  following  tests :  standing 
with  feet  together  and  eyes  closed  (Rhomberg),  standing  upon  one  foot 
then  the  other,  gait  forward,  gait  backward,  hopping  upon  one  foot 
forward  and  backward,  all  of  these  tests  were  made  both  with  open 


186  UTRICVLUS  A\'D  SACCULUS. 

and  closed  eyes.  Elevation  upon  the  Alexander-Stein  goniometer 
\vith  face  toward  the  instrument,  first  with  eyes  open  then  with 
eyes  closed,  with  face  away  from  the  instrument,  with  right  side  to- 
ward the  instrument  and  with  left  side  toward  the  instrument :  all  of 
which  were  made  with  eyes  open  and  with  eyes  closed.  To  avoid  slip- 
ping on  the  goniometer  the  patients  were  examined  with  bare  feet,  and 
the  instrument  was  dusted  with  rosin.  In  some  cases  the  examinations 
were  repeated  in  order  to  be  absolutely  certain  of  the  results.  Many  of 
the  patients  were  examined  repeatedly  at  wide  intervals.  The  time  re- 
quired in  collecting  and  examining  the  material  extended  over  a  period 
of  ten  months. 

Without  going  into  too  many  details,  individuals  with  a  one  sided 
labyrinth  destruction  showed  diminished  ability  to  equilibrate,  while 
those  with  double  sided  labyrinth  destruction  showed  marked  disturb- 
ance, in  some  cases  amounting  to  an  almost  complete  loss  of  equilib- 
rium when  the  eyes  were  closed.  These  disturbances  were  always  more 
marked  when  the  eyes  were  closed  than  when  they  were  open. 

The  equilibrium  tests  enumerated  did  not  include  rotational  move- 
ments, so  we  must  exclude  the  semicircular  canals  as  a  factor  in  these 
cases.  No  doubt  these  patients  would  have  shown  the  same  degree  of 
equilibrium  disturbances  by  rotational  movement  tests  (determined 
previously  by  James  and  Breuer  and  others)  as  by  the  tests  selected. 

Since  the  patients  showed  positive  equilibrium  disturbances,  in- 
creased by  closure  of  the  eyes,  and,  furthermore,  since  every  other 
possible  factor  had  been  eliminated  we  must  conclude  that  the  equilib- 
rium disturbance  was  due  to  a  loss  of  some  organ  of  equilibrium  lo- 
cated in  the  inner  ear. 

Finally,  if  the  loss  of  equilibrium  was  due  to  destruction  of  some- 
thing within  the  inner  ear  and  the  tests  employed  were  not  rotational 
(thus  excluding  the  semicircular  canals),  then  it  follows  that  the  lost 
function  must  have  been  due  to  the  destruction  of  the  vestibular  sacs. 
The  writer  in  his  work  on  labyrinthine  equilibrium  disturbances  de- 
clared in  favor  of  the  Breuer  theory,  which  in  part  declares  the  func- 
tions of  the  utriculus  and  sacculus  to  be  that  of  perception  of  straight 
line  (progressive)  movements,  allowing  the  functions  of  the  semi- 
circular canals  to  be  for  the  perception  of  turning  movements. 


LABYRINTH  PAPERS.  187 


THE  WRITER  S  CONCLUSIONS. 

The  functions  of  the  utriculus  and  sacculus  are  both  static  and 
dynamic. 

Static — for  the  perception  of  position  in  space. 

Dynamic — for  the  perception  of  straight  line  (progressive)  move- 
ments in  any  direction,  so  long  as  the  movement  is  increasing  or  dimin- 
ishing in  velocity. 

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LABYRINTH  PAPERS.  189 

28.  Barany — "Physiologic  u.   Pathologic  des   Bogen  Appar  beim 
menchen."    A  monograph,  Deuticke.,  Wein,  1907. 

29.  MacKenzie — "Klinische  Untersuchungen  ueber  Labyrinthaeren 
Gleichgewichtsstoerungen  mit  besonderer  Bereuchsichtigung  der  allge- 
meinen  Pruefungsmethoden  und  des  Goniometers" — Arch.  f.  Ohren- 
heilk,  Bd.  78,  1909. 

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schwindel  der  Taubstunvnen" — Zeitsch.  f.  Ohrenheilk,  1904. 

31.  Krotoscheiner — Zeit.  f.  Ohrenheilk,  Bd.  51  and  52. 

32.  Kummels — "Ueber     infectioese    Labyrinth     Erkrangungen" — 
Zeitschrift  fur  Klinische  Mediz.,  Bd.  55,  1904. 

33.  Yon  Stein — "Ueber  Gleichgewichtsstoerungen  bie  Ohrenleiden" 
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VERTIGO. 

THE  subject  of  vertigo  has  become  one  of  importance,  espe-> 
cially  in  view  of  the  recent  advances  made  in  our  knowledge 
of  the  physiology  and  pathology  of  the  ear  labyrinth. 
Although  vertigo  in  conjunction  with  nystagmus  and  equilibrium 
disturbances  has  been  referred  to  in  every  recent  publication  upon  the 
labyrinth  and  diseases  of  the  labyrinth,  writers  as  a  rule  have  not 
attempted  to  make  clear  to  the  minds  of  their  readers  exactly  what  is 
meant  by  the  term.    As  a  result,  not  only  the  laity  but  some  physicians 
have  but  a  vague  conception  of  the  symptom.     I  find  this  especially 
so  when  noting  the  history  of  the  cases.     Of  all  those  who  claim  to 
have  vertigo,  upon  close  questioning  I  find  that  many  have  not.    I  am, 
therefore,  prompted  to  write  a  paper  upon  this  subject. 

WHAT   IS   VERTIGO? 

I  agree,  in  substance,  with  Panse  that  vertigo  in  its  broadest  sense 
is  that  sensation  of  confusion  which  results  from  any  false  perception 
of  one's  relative  position  to  space  or  motion  in  space. 

Normally  one  is  aware  of  the  fact  whether  he  is  standing  vertically 
erect,  inclined  forward,  backward  or  to  either  side,  sitting  or  lying 
down ;  whether  he  is  moving  in  a  straight  line  forward,  backward  or 
to  either  side,  vertically  upward  or  downward;  whether  he  is  moving 
in  a  circle  in  any  of  the  three  principal  planes  or  resultant  of  these 
planes. 

Furthermore,  one  is  aware  of  the  fact  whether  surrounding  objects 
are  out  of  plumb,  so  to  speak,  inclined  toward  or  away  from  him,  to 
one  or  the  other  side.  Finally  one  is  able  to  determine  whether  ob- 
jects are  stationary  or  in  motion,  and  when  in  motion  whether  they 
are  moving  toward  or  away  from  him,  to  one  or  the  other  side,  ver- 
tically upward  or  downward,  in  a  circle  in  front  of  him  etc. 

We  are  made  conscious  of  these  positions  and  motions,  subjective  or 
objective,  through  three  different  peripheral  sense  organs  and  their 
centripetal  tracts,  i. — Thru  the  visual  organ,  the  eyes,  including 
their  intrinsic  and  extrinsic  muscles ;  2. — Thru  the  equilibrium 
sense  organs,  the  nonacoustic  labyrinth;  3. — Thru  the  kinesthetic  sense 
organs;  the  deep  muscles,  joints,  sensory  nerve  endings  all  over  the 


LABYRINTH  PAPERS.  191 

body,  which  may,  since  their  functions  are  identical,  be  classed  as  one 
organ. 

The  normal,  physiologic,  correlation  of  these  three  centripetal  im- 
pulses from  the  eyes,  ears  (nonacoustic  labyrinth)  and  muscles  and 
joints,  and  possibly  the  skin  and  viscera,  enables  one  to  maintain  per- 
fect equilibrium  of  the  body  when  at  rest  (static)  and  during  motion 
(dynamic). 

According  to  Bechterew,  quoted  by  Panse,  the  correlation  of  all 
these  centripetal  impulses  takes  place  in  the  cerebellum.  Any  sudden 
falsification  of  sensation  from  one  of  these  organs — whether  pro- 
duced experimentally  or  pathologically — produces  that  unpleasant  sen- 
sation of  confusion  known  as  vertigo  and  in  proportion,  equilibrium 
disturbances.  However,  a  falsification  of  sensation  from  any  one  of 
these  three  sensory  organs  if  continued  will  eventually  be  corrected 
by  the  remaining  two.  With  this  correction  comes  a  relief  of  the 
vertigo.  In  other  words,  the  contradictory  or  false  sensation  will  be 
suppressed  while  the  remaining  virtual  sensations  will  be  accepted. 

These  above  conditions  are  true  only  in  so  far  as  they  apply  to 
cases  of  permanent  and  fixed  falsification ;  for  instance :  in  cases  of 
labyrinth  suppuration,  those  of  permanent  eye  muscle  paralysis,  etc. 
On  the  other  hand,  vertigo  may  recur  in  cases  of  variable  falsification, 
for  instance  in  cases  of  irritative  lesions  or  in  those  cases  of  partial 
loss,  followed  by  subsequent  restitution  of  function.  In  cases  of  tem- 
porary eye  muscle  paresis  when  the  affected  muscle  begins  to  func- 
tionate again  we  may  find  vertigo  accompanied  with  nystagmus  during 
attempts  to  roll  the  eye  in  the  direction  of  the  muscle's  action;  ob- 
served by  Stewart  (Deutsches  Median.  Zcitschr..  1895,  seite  511)  an(^ 
others,  including  the  writer. 

While  vertigo  is  always  accompanied  by  pronounced  equilibrium  dis- 
turbances the  reverse  is  not  true. 

At  this  writing  I  wish  to  deny  the  claim  of  some  authors,  quoted  by 
the  writer  in  one  of  his  recent  papers  upon  labyrinth  suppuration,  that 
vertigo  is  always  associated  with  nystagmus. 

Although  vertigo  may  disappear  after  a  few  days  in  cases  of  per- 
manent loss  of  function  of  one  of  these  end  organs  and  the  equilibrium 
disturbances  may  become  less  pronounced,  there  still  remains  a  slight 
degree  of  permanent  equilibrium  disturbance.  This  is  theoretically, 
mathematically  and  practically  so  as  shown  by  the  writer  in  a  recent 


192  I'ERTIGO. 

paper  upon  the  subject  of  equilibrium  disturbances,  entitled  "Klinische 
Untersuchungen  ueber  die  labyrintharen  Gleichgewichtsstoerungen  mit 
besonderer  Berucksichtigung  der  allgemeinen  Pruefungsmethoden  und 
des  Gonimeters"  (Archiv.  f.  Ohrenhlk.,  band  78,  Feb.,  1909.) 

If  three  different  sets  of  centripetal  impulses  are  necessary  for  per- 
fect orientation  and  equilibration,  it  must  follow  that  when  one  of  these 
is  lost,  orientation  and  equilibration  must  be  disturbed  in  proportion ; 
however,  with  the  remaining  two  impulses  one  learns  rapidly  to  orien- 
tate and  equilibrate,  quite  sufficiently  for  ordinary  purposes.  In  fact 
one  may  get  along  so  well  under  favorable  circumstances  as  to  almost 
conceal  the  presence  of  his  equilibrium  disturbance ;  but  careful  tests 
of  such  patients  by  Von  Stein,  Krotoscheiner,  Kreidl,  Alexander  and 
Mackenzie  have  never  failed  to  prove  their  presence. 

\Yhen  a  second  of  these  centripetal  impulses  is  lost,  naturally 
orientation  and  equilibration  are  disturbed  still  further,  and  proportion- 
ately more  than  when  the  first  impulse  alone  was  lost. 

Sudden  falsification  of  sensation  from  one  of  these  three  peripheral 
sense  organs  leads  not  only  to  vertigo,  -as  already  stated,  but  also  to 
pronounced  equilibrium  disturbance,  nausea  and  vomiting,  vasomotor 
changes — flushing  or  more  frequently  pallor  of  the  face — profuse 
sweating,  etc. 

The  sensation  and  intensity  of  the  vertigo  differs  in  different  cases 
according  to  which  of  the  three  special  end  organs  or  centripetal  tracts 
is  involved. 

In  the  case  of  vertigo  resulting  from  experimental  irritation  of,  or 
pathologic  lesion  in,  the  labyrinth  or  its  centripetal  tracts,  the  vertigo 
is  always  of  the  type  called  rotational ;  that  is  to  say,  the  patient  suffers 
either  the  sensation  as  though  external  objects  were  in  motion  or  else 
the  sensation  of  subjective  motion.  Whether  the  sensation  of  motion 
is  referred  to  external  objects  or  to  the  patient  himself,  these  motions 
are  in  circles  in  one  of  the  three  principal  planes  or  resultant  of  these 
planes. 

Rotational  vertigo  is  perhaps  the  most  intense  and  unpleasant  form 
and  is  always  combined  with  nystagmus. 

While  vertigo  the  result  of  affection  of  the  labyrinth  or  its  centri- 
petal tracts  is  always  rotational  in  Character  and  is  combined  with 
nystagmus,  it  does  not  follow  that  every  rotational  vertigo  combined 
with  nystagmus  must  necessarily  be  produced  by  disease  of  the  laby- 


LABYRINTH  PAPERS.  193 

rinth  or  its  centripetal  tracts;  for  on  the  contrary  we  find  rotational 
vertigo  and  nystagmus  in  cases  of  vertigo  produced  by  a  lesion  in 
the  eye — or,  more  exactly,  in  cases  of  eye  muscle  paresis  during  the 
stage  of  improvement  (Panse).  However,  as  a  rule  rotational  vertigo 
indicates  a  lesion  in  the  labyrinth  its  centripetal  tracts  or  their  ter- 
minals in  the  cerebellum. 

In  the  case  of  vertigo  resulting  from  disease  of  the  eye  or  eye  mus- 
cles, excepting  in  the  case  above  mentioned,  the  patient's  sensation 
of  vertigo  is  referred  to  external  objects ;  they  seem  too  near  or  too 
distant,  inclined  toward  or  away  from  him  to  one  or  the  other  side, 
or  the  floor  upon  which  the  patient  is  standing  is  inclined  in  one  of 
these  directions,  etc.,  and  on  account  of  which  the  patient  is  in  danger  of 
making  false  steps  and  movements.  He  misjudges  the  distances  and 
directions  of  objects. 

This  ocular  form  of  vertigo  is  less  intense  as  a  rule  than  the  vesti- 
bular  form  and  is  unassociated  with  nystagmus  except  in  the  case 
previously  referred  to. 

Ocular  vertigo  is  characteristically  ameliorated  by  closure  of  the 
eyes,  whereas  the  former  vestibular  or  rotational  is  uninfluenced.  This 
is  quite  an  important  differential  test  for  these  two  forms. 

In  contrast  with  the  ocular  vertigo  we  have  the  vertigo  due  to  falsi- 
fication of  centripetal  impulses  from  the  muscles,  joints,  etc.,  (the  so- 
called  deep  sensibility).  In  this  form  of  vertigo,  for  we  may  call  it 
so — accepting  the  broad  definition,  the  patient  perceives  the  external 
world  in  its  normal  relations,  but  suffers  the  subjective  sensation  as 
though  he  himself  was  out  of  plumb  with  it.  He  feels  as  though  he 
is  tilted  forward,  backward,  or  to  one  or  the  other  side,  or  else  when 
making  a  movement  he  believes  he  has  made  it  either  too  great  or  too 
slight;  in  other  words,  he  is  not  properly  informed  of  either  the  ex- 
tent or  character  of  the  movement,  his  perception  of  the  movement 
(excepting  when  aided  by  the  eyes)  causes  him  to  innervate  too  strong- 
ly or  not  strongly  enough ;  he  makes  incorrect  movements  believing  he 
has  made  them  correctly. 

In  contrasting  the  kinesthetic  form  of  vertigo  with  the  ocular  it 
may  be  said  that  while  ocular  vertigo  is  improved  by  closure  of  the 
eyes,  the  kinesthetic  form  is  made  worse  and  its  accompanying  phe- 
nomenon equilibrium  disturbance,  is  decidedly  aggravated. 

Let  us  consider  next  some  of  the  more  definite  causes  of  and  the 
sensations  produced  by  these  three  separate  forms  of  vertigo. 
13 


194  I'ERTIGO. 

I.  Rotational  or  vestibular  vertigo  may  be  produced  experimentally 
or  pathologically.  Experimentally  by  : 

(a)  turning  (as  first  practiced  by  Flourens)   in  a  revolving  chair. 
This  should  be  done  with  the  patient's  eyes  closed  during  the  turning 
in  order  to  obtain  a  pure  vestibular  form,  otherwise  a  combination  of 
vestibular  and  the  ocular  is  produced. 

(b)  caloric  irritation  of  the  nonacoustic  labyrinth. 

(c)  galvanism  with  opposite  electrodes  applied  to  opposite  sides  of 
the  head  or  with  one  electrode  applied  to  the  region  of  the  ear  and 
the  other  applied  to  some  other  part  of  the  body,  say  the  hand. 

(d)  mechanical  irritation  of  the  semicircular  ca'nals  after  the  mannei 
of  Ewald's  experiment. 

(e)  sectioning  one  or  both  of  the  8th  nerve  stems. 

(f)  removal  of  a  cerebellar  hemisphere.     These  latter  three  expen- 
ments  are  not  applicable  to  human  subjects. 

Pathologically  by : 

(a)  any  lesion  in  the  nonacoustic  labyrinth:  including  congestion, 
circumscribed  irritative  or  destructive  lesions,  diffuse  serous  or  sup- 
purative  inflammations,  toxemias,  growths,  etc. 

(b)  any  lesion  in  the  vestibular  nerve:  nueritis,  tumors,  basal  fract- 
ures, meningitis,  etc. 

(c)  any  intracranial  lesions   involving  the  nuclei  or  tracts  to  the 
cerebellum  or  the  cerebellum  itself. 

In  the  case  of  vertigo  produced  by  any  of  these  causes,  experimental 
or  pathologic,  the  sensation  of  subjective  or  objective  turning  is  pro- 
duced. The  vertigo  persists  even  with  the  eyes  closed. 

With  the  eyes  closed  the  sensation  is  that  of  subjective  turning ;  the 
patient  feels  as  though  he  is  being  turned.  With  the  eyes  open  the 
sensation  is  generally  that  of  objective  turning,  the  patient  feels  as 
though  surrounding  objects  were  turning.  The  direction  and  plane  of 
the  turning  is  dependent  upon  the  direction  and  plane  of  the  nystagmus 
which  is  constantly  present  in  this  form  of  vertigo. 

The  equilibrium  disturbance  manifests  itself  by  falling  or  turning 
in  the  opposite  direction  to  and  in  the  plane  of  the  nystagmus.  This 
falling  results  from  the  efforts  of  the  patient  to  correct  the  sensation 
of  apparent  falling.  Like  the  sensation  of  vertigo,  the  equilibrium 
disturbance  is  manifest  even  more  with  the  eyes  closed  than  when 
open.  Again  by  the  aid  of  touch  and  the  deep  muscle  sense,  the  pa- 


LABYRINTH  PAPERS.  IQ5 

tient  is  aided  in  maintaining  equilibrium :  which  accounts  for  the  fact 
that  patients  suffering  with  vestibular  vertigo  immediately  grasp,  for 
support,  the  nearest  fixed  object. 

II.     Ocular  vertigo  may  be  produced  experimentally  or  pathologi- 
cally.   Experimentally  by: 

(a)  sudden  disturbance  of  vision,  especially  when  monocular;  for 
instance  by  the  placing  of  strong  concave  or  convex  spherical  lenses 
before  om   or  both  eyes  or  the  placing  of  a  minus  glass  before  one 
eye  and  a  prus  glass  before  the  other.    The  convex  glass,  because  ot 
the  magnification,  produces  the  sensation  of  nearness  of  objects  while 
the  indistinctness  of  the  outlines  and  details  produces  the  contradictory 
sensation  of  remoteness.    The  concave  glass  produces  just  the  opposite 
contradiction  of  sensations. 

(b)  the  placing  of  plus  or  minus  cylinders  before  the  eyes  producer 
distortion  of  objects,  irregularity  in  angles,  etc. ;  for  instance,  right 
angles  are  made  to  appear  too  acute  or  too  obtuse,  dependent  upon 
whether  a  plus  or  minus  cylinder  is  used  and  the  axis  to  which  it  may 
be  turned. 

(c)  sudden  paralysis  of  accommodation  with  dilatation  of  the  pupil 
produced  by  a  mydriatic  will  cause  vertigo,  especially  in  those  suffering 
from  considerable  latent  hyperopia  or  hyperopic  astigmia.     The  pa- 
tients complain  usually  of  objects,  especially  the  floor,  being  too  near 
or   distant,   dependent   upon   the   amount   and   axis   of   the   manifest 
astigmia. 

(d)  The  placing  before  the  eyes  of  prisms,  whether  strong  enough 
to  produce  diplopia  or  not,  will  cause  vertigo.    The  placing  of  prisms, 
bases  in  the  same  direction,  produces  slanting  effects  of  external  ob- 
jects and  false  impression  of  location.    The  placing  of  the  bases  in  op- 
posite  directions,   if  strong  enough,   produces   diplopia   with   vertigo. 
On  the  other  hand,  the  use  of  weaker  prisms,  insufficient  to  produce 
diplopia,  produces  a  vertigo  often  more  intense  than  that  produced 
by  the  stronger  prisms.     \Yith  the  weaker  prism  producing  vertigo, 
there  is  always  associated  nystagmus  directed  toward  the  apex  of  the 
prism.     In  the  case  of  vertigo  produced  by  prisms,  the  patient  is  con- 
fused most  as  to  the  direction  of  external  objects. 

(e)  Tenotomy  or  section  of  the  nerve  supply  to  one  of  the  extrinsic 
muscles  produces  similar  effects  to  that  produced  by  prisms. 

(f)  Pressure  of  the  finger  upon  the  one  eyeball  may  so  change  the 
direction  of  the  visual  axis  as  to  produce  diplopia  with  vertigo,  etc. 


196  I'ERTIGO. 

(g)  There  is  a  form  of  vertigo  combined  with  nystagmus,  which  we 
may  conveniently  term  visual  rotational  vertigo  and  may  be  produced 
experimentally  by  gazing  for  a  long  time  at  moving  objects — water- 
falls, rapidly  moving  currents,  carousal,  windmills  in  motion — or  by 
Mack's  rotating  cylinder,  etc.  After  looking  for  a  long  time  at  one 
of  these  moving  objects  and  then  looking  away  at  stationary  sur- 
roundings the  patient  suffers  the  sensation  of  a  mild  rotational  vertigo, 
whereby  the  stationary  objects  appear  to  be  moving  in  a  contrary  di- 
rection, and  when  this  vertigo  is  pronounced  it  is  accompanied  by 
equilibrium  disturbance  characteristic  of  rotational  vertigo.  This  ver- 
tigo is  similar  to  the  vertigo  associated  with  the  socalled  after-turning 
nystagmus ;  the  character  of  the  vertigo  might  suggest  the  presence  of 
rhythmic  nystagmus,  but  up  to  the  present  time  the  writer  has  been 
unable  to  demonstrate  it. 

On  the  other  hand  an  experiment  practiced  by  the  writer  would  sug- 
gest the  absence  of  nystagmus.  The  experiment  is  made  as  follows: 
Seated  on  the  rear  end  of  a  moving  train  (observation  platform)  one 
directs  his  view  straight  ahead  at  some  distant  receding  point  for 
about  30  to  40  seconds.  This  produces  no  nystagmus,  but  naturally 
the  sensation-  as  though  the  field  of  vision  was  receding.  Should  the 
train  come  to  a  stop,  or  should  one  direct  his  gaze  at  some  stationary 
object  (within  the  car)  the  sensation  of  reversed  motion  is  produced 
lasting  for  several  seconds.  This  is  an  ocular  form  of  after-motion 
vertigo,  and  is  unassociated  with  nystagmus.  This  visual  sensation 
of  reversed  motion  is  furthermore  unassociated  with  any  labyrinthine 
function  from  the  fact  that  it  can  be  produced  only  with  the  eyes 
open. 

Pathologically  by : 

(a)  Sudden  irregular  swelling  of  the  lens,  as  sometimes  found  in 
incipient  cataract,  may  cause  polyopia  with  unpleasant  vertigo. 

(b)  Sudden  blindness  from  a  lesion  in  the  perceiving  apparatus, 
retina  and  optic  nerve — tho  it  causes  a  loss  of  the  perspective  sense 
seldom  if  ever  produces  unpleasant  vertigo,  from  the  fact  that  we  have 
long   since  learned  to  accommodate   ourselves   to   monocular   vision. 
The  nail  driving  experiment  with  one  eye  closed  is  familiar  to  you  all. 

(c)  Lesions   especially   in   the   short   optic   tracts   to  the   ganglion 
genicula  externa,  corpora  quadrigemina  anterior  and  the  pulvinar — 
and  perhaps  too,  in  a  measure,  the  long  tracts  to  the  visual  centers  in 


LABYRINTH  PAPERS.  197 

the  occipitial  lobe,  produce  not  infrequently  vertigo  with  equilibrium 
disturbances — according  to  Bechterew  (Deutsche  Med.  Zeitung,  1894, 
No.  46).  These  are  produced  in  the  former  instance  by  disturbances 
more  especially  in  the  pupillary  and  accommodation  reflex  arc  and  in 
the  latter  instance  by  disturbance  in  visual  perception. 

(d)  Sudden  paralysis  of  accommodation  from  a  lesion  in  the  ciliary 
muscle  itself,  nerve  supply,  ciliary  ganglion,  that  part  of  the  oculomotor 
nucleus  which  controls  accommodation,  produces  the  sensation  of  ver- 
tigo with  equilibrium   disturbance,   similar  to  that  produced  by   my- 
driatics. 

(e)  Sudden  paralysis  of  one  or  more  of  the  extrinsic  eye  muscles 
from  lesion  in  the  muscle,  nerve  or  nucleus,  produces  diplopia  with 
vertigo. 

The  sensation  as  well  as  the  mechanism  of  vertigo  produced  by 
complete  paralysis  of  one  of  the  extrinsic  eye  muscles  differs  from  that 
produced  by  slight  paresis. 

In  case  of  paralysis,  the  patient  manifests  real  squint  but  no  nystag- 
mus ;  the  patient  suffers  diplopia  and  a  sensation  of  confusion  (ver- 
tigo) as  to  the  location  of  external  objects,  especially  objects  located 
to  the  side  or  direction  of  the  muscle's  action.  For  example :  in  case 
of  paralysis  of  the  right  external  rectus,  the  location  of  objects  to  the 
right  are  estimated  to  be  farther  to  the  right  than  they  actually  are. 
The  reason  is  that  since  we  have  learned  to  estimate  the  location  of 
objects  by  the  amount  of  muscle  innervation  necessary  to  fix  the  ob- 
jects for  central  vision,  any  extra  amount  of  innervation  put  forth  in 
the  attempt  to  fix  them  is  interpreted  by  the  patient  as  an  extra  amount 
of  angle  deviation  of  the  object  to  the  right.  This  is  associated  with  a 
corresponding  amount  of  secondary  deviation  of  the  fellow  eye  to  the 
right.  Such  a  patient  in  attempting  to  grasp  an  object  lying  to  the 
right  of  him  will  invariably  reach  too  far  to  the  right.  In  brief,  there 
is  confusion  as  to  the  location  of  external  objects. 

In  the  case  of  slight  paresis,  or  in  those  cases  of  late  paralysis  where 
a  restoration  of  function  has  begun  in  the  affected  muscle,  the  sensa- 
tion and  mechanism  of  the  vertigo  is  quite  different.  In  these  cases  the 
patient  may  manifest  but  little  or  no  squint,  but  instead  will  show 
rhythmic  nystagmus,  especially  when  looking  in  the  direction  of  the 
muscle's  action.  The  vertigo  is  present  only  when  looking  in  the  di- 
rection of  the  paretic  muscle,  is  rotational  in  character  and  associated 


igs  VERTIGO: 

with  equilibrium  disturbance  corresponding  to  rotational  vertigo.  This 
trio  of  symptoms — rhythmic  nystagmus,  vertigo  and  equilibrium  dis- 
turbance— may  simulate  closely  the  vestibular  form ;  the  nystagmus  of 
eye  muscle  paresis  is  more  likely  to  be  unilateral,  and  less  intense  than 
in  the  case  of  nystagmus  of  the  vestibular  form.  Again,  the  vertigo 
of  eye  muscle  paresis  differs  from  that  of  the  vestibular  form  in  that 
the  vertigo  improves  upon  closure  of  the  eyes ;  whereas  the  vestibular 
form  does  not. 

III.  Kinesthetic  vertigo.  That  vertigo  may  be  produced  by  falsi- 
fication of  sensory  impulses  from  the  muscles,  joints,  etc.,  may  seem 
to  some  far  fetched ;  nevertheless  the  fact  is  true  if  we  accept  the 
broad  definition  of  the  term  offered  in  the  early  part  of  the  paper. 
For  instance : 

The  vertigo  resulting  from  paresis  of  the  eye  muscles  is  produced 
by  two  factors:  (i)  visual  (diplopia)  and  (2)  muscular  (falsifica- 
tion of  sensation  of  the  affected  muscle).  The  concomitant  equilib- 
rium disturbances  would  indicate  that  the  vertigo  results  more  from 
the  falsification  of  sensory  impulses  from  the  muscles  than  from  the 
diplopia.  The  author  has  arrived  at  this  conclusion  from  the  results 
obtained  by  equilibrium  tests  made  upon  patients  suffering  from  pa- 
ralytic squint.  These  patients  were  examined  ( I )  with  both  eyes  open  ; 
(2)  with  the  affected  eye  closed,  and  (3)  with  the  well  eye  closed,  the 
patients  being  directed  to  look  in  the  direction  of  the  action  of  the 
paralyzed  muscle. 

With  both  eyes  open,  the  gait  and  equilibrium  were  disturbed. 

With  affected  eye  closed,  the  gait  and  equilibrium  were  quite  normal. 

With  the  well  eye  closed,  gait  and  equilibrium  were  disturbed  and 
quite  as  markedly  so  as  when  both  eyes  were  open. 

Kinesthetic  vertigo  may  be  produced  experimentally  or  pathologi- 
cally. The  production  of  experimental  kinesthetic  vertigo  has  been 
only  partially  successful,  from  the  fact  that  the  deep  muscle  and  joint 
sensibilities  are  so  widely  distributed  over  the  entire  body  as  to  make 
it  quite  impossible  to  irritate  or  anesthetize  a  sufficient  proportion  of 
them  to  produce  marked  vertigo  and  equilibrium  disturbance.  The 
results  of  experiments  thus  far  made  have  been  sufficiently  successful 
however  to  warrant  further  experimentation  after  more  improved 
methods.  A  few  of  these  experiments  may  be  mentioned : 

(a)  Anesthesia  of  the  soles  of  the  feet  produced  artificially  has  re- 


LABYRINTH  PAPERS.  199 

suited  in  the  subject  manifesting  positive  Rhomberg  sign  and  disturbed 
gait  (Vierordt's  experiment  quoted  by  Bechterew.  P finger's  Arch. 
xxx,  s.  517). 

(b)  Experiments  by  Mach  with  the  two  feet  placed  air  tight  in  two 
holes  in  a  box  resulted  in  the  sensation  as  though  the  floor  was  ele- 
vated when  aspiration  of  air  from  the  box  was  made. 

(c)  Further  experiments  by  Mach  with  weights  (vessels  containing 
water)  held  in  the  hand  or  attached  to  the  shoulders  caused  the  sen- 
sation as  though  the  arms  or  body  were  elevated  when  the  load  was  re- 
moved. 

(d)  Panse  tells  of  an  interesting  experiment  made  by  Mach,  as  fol- 
lows :  two  vessels  so  constructed  as  to  permit  a  gradual  emptying  when 
filled  with  water,  were  adjusted  to  a  cap  arrangement  fitted  on  the 
head ;  this  when  set  in  horizontal  rotation,  produced,  as  the  weight  di- 
minished from  loss  of  water,  the  subjective  sensation  of  turning  in  the 
opposite  direction. 

(e)  Bechterew   (Pfiuger's  Arch,  xxxiv)  found  that  section  of  the 
posterior  cerebellar  peduncle  caused  animals  to  roll  to  the  side  operated. 

Kinesthetic  vertigo  with  equilibrium  disturbance  may  be  produced 
pathologically  by : 

(a)  Acute  polyneuritis,  involving  sensory  nerves. 

(b)  Diseases  involving  the  posterior  columns,  Gall  and  Burdach  or 
spinocerebellar  tracts  in  the  cord,  tabes,  Friedrich's  disease,  multiple 
sclerosis  of  the  cord,  hemorrhages  and  myelitis  in  the  cord,  etc. 

(c)  Diseases  in  the  corpus  restiforme,  interrupting  the  centripetal 
impulses. 

In  all  these  and  others  not  mentioned  the  equilibrium  disturbance  is 
a  more  pronounced  symptom  than  the  vertigo,  and  lasts  permanently 
in  cases  of  permanent  destructive  lesions.  Furthermore,  the  equilib- 
rium disturbance  from  interruption  of  these  impulses  is  even  more  pro- 
nounced than  in  the  case  of  interruption  of  impulses  from  the  eye  while 
the  vertigo  is  less  pronounced. 

Vertigo  is  never  complained  of  as  being  so  unpleasant  as  in  the  case 
of  interruption  of  impulses  from  the  eye  or  ear.  This  is  due  to  two 
circumstances:  (i)  That  the  disease  which  produce  interruption  of 
sensation  from  the  muscle  and  joint  sense  endings  is  very  rarely  acute, 
except  in  the  case  of  acute  hemorrhagic  lesions ;  and  (2)  That  these 
diseases  are  very  rarely  extensive  enough  at  the  onset.  On  the  con- 


2oo  I'ERTIGO. 

trary,  they  are  usually  gradual  progressive  conditions  which  permit 
the  patient  to  become  gradually  accommodated  to  the  changes. 

The  vertigo  and  equilibrium  disturbances,  like  those  of  vestibular 
origin,  are  exaggerated  by  closing  the  eyes. 

CENTRAL    VERTIGO. 

Finally  we  come  to  a  discussion  of  that  large  class  of  so-called  cen- 
tral vertigoes. 

By  central  vertigo  is  not  meant  the  vertigo  which  results  from 
anatomic  changes  in  the  brain  substance  itself,  which  presents,  accord- 
ing to  the  location  of  the  lesion,  the  characteristic  of  one  of  the  three 
definite  types  already  referred  to ;  but  on  the  contrary,  by  central  ver- 
tigo is  meant  that  form  of  vertigo  which  is  due  to  circulatory  dis- 
turbances in  the  brain  or  to  toxic  substances  circulating  in  the  blood 
current;  and  it  presents  a  combination  of  the  several  characteristics 
of  all  three  types.  In  other  words,  central  vertigo  differs  from  each 
of  the  three  described  types — or  primary  forms — in  that  the  manifesta- 
tions in  the  primary  forms  are  distinct  and  definite ;  while  in  the  cen- 
tral forms  they  are  not. 

That  central  vertigo  should  present  the  combined  features  of  all  three 
primary  forms,  but  less  defined  and  distinct  than  any  one  of  them  is 
quite  evident  when  we  recall  the  etiology. 

In  the  primary  forms  we  have  a  vertigo  due  to  a  well  defined  ex- 
aggeration or  suppression  of  the  normal  impulses  from  one  of  the  three 
peripheral  orientation  organs  through  an  irritative  or  destructive  lesion 
in  these  organs  or  their  centripetal  tracts,  while  in  the  central  vertigo 
due  to  circulatory  disturbances  the  exaggeration  or  suppression  of  im- 
pulses are  more  general  and  less  pronounced ;  for  instance,  in  the  case 
of  congestion  or  anemia  of  the  brain  the  whole  brain  suffers  whereby 
all  centers  are  more  or  less  affected.  Again,  in  the  case  of  toxemia  the 
toxic  substance  circulating  in  the  blood  current  is  never  so  selective 
in  its  action  as  to  affect  the  centers  for  one  of  these  impulses  to  the 
exclusion  of  the  remaining  two.  However,  exceptional  cases  do  occur 
where  the  toxic  substance  may  be  sufficiently  selective  in  its  action 
as  to  affect  certain  centers  more  than  others  when  the  resulting  vertigo 
may  present  the  characteristics  of  one  primary  form  more  prominently 
than  the  other  two.  In  such  cases  a  differential  diagnosis  of  the  cen- 
tral vertigo  from  the  primary  forms,  which 'it  resembles,  may  be  quite 


LABYRINTH  PAPERS.  201 

difficult.  A  similar  condition  may  result  in  cases  of  arteriosclerosis  or 
endarteritis  where  certain  vessels  may  be  more  affected  than  others — 
or  where  the  blood  vessels  make  a  sharp  turn,  or  in  cases  where  vessels 
branch  off  from  the  main  stem  at  a  sharp  angle. 

Central  vertigo  may  be  produced  by  the  following  familiar  condi- 
tions : 

I.  Cerebral  congestion,  active  or  passive,  from  any  cause 

II.  Cerebral  anemia. — Psychic  or  physical   shock  producing   syn- 
cope.    Insufficiency  of  the  heart's  action.     Post-hemorrhagic  anemia. 
General  anemia,  including  chlorosis,  pernicious  anemia,  etc.     Change* 
in  the  blood  vessels  narrowing  their  lumen ;  arteriosclerosis,  endarter- 
itis, etc. 

III.  Toxemias,  acute  or  chronic. 

Acute:  Tobacco,  alcohol,  carbon  dioxide,  ether,  chloroform,  ben- 
zine and  the  inhalation  of  other  volatile  toxic  substances. 

Chronic :  Tobacco,  alcohol,  lead,  etc.  Uremia,  autointoxication. 
Toxemias  associated  with  the  acute  infectious  fevers,  etc. 

All  vertigoes  are  aggravated  by  change  of  body  position,  especially 
from  lying  down  to  standing  up.  This  aggravation  is  more  pronounced 
in  the  case  of  vertigo  from  cerebral  anemia  than  in  the  case  of  vertigo 
from  any  other  cause.  This  has  been  felt  at  some  time  in  the  experi- 
ence of  most  of  us,  especially  after  a  depleting  illness,  which  at  the 
same  time  required  us  to  remain  in  bed  for  some  days  or  weeks. 

Concerning  vertigo  of  gastric  origin  the  writer  is  quite  skeptical. 
It  is  true  that  the  ingestion  of  certain  toxic  substances  produces  vomit- 
ing with  vertigo,  but  in  these  cases  the  author  believes  that  the  vomit- 
ing is  merely  a  symptom  of  the  vertigo,  and  the  toxic  substances  in- 
gested would  produce  vertigo  at  all  events  even  though  the  patient  did 
not  reach  a  stage  where  vomiting  resulted.  If  irritation  of  the  pneu- 
mogastric  was  the  cause  of  the  vertigo  then  it  must  follow  that  all  sub- 
stances which  are  capable  of  producing  emesis  should  at  the  same  time 
produce  vertigo.  Since  this  is  not  the  case,  but  the  reverse  is  true, 
then  it  follows  that  nausea  and  vomiting  are  the  results  and  not  the 
cause  of  the  vertigo. 


LABYRINTH  FISTULA. 

WHAT    IS   A    LABYRINTH    FISTULA? 

A    LABYRINTH  fistula  consists  of  any  loss  of  substance  in  the 
osseous  labyrinth  which  permits  an  artificial  path  of  communi- 
cation between   its  cavity  and  the  middle  ear  space.     They 
vary  in  size,  shape  and  location;  generally  occur  as  single  perforations, 
but  may  be  found  multiple. 

The  most  frequent  locations  of  labyrinth  fistula  are/  naturally  the 
most  exposed,  and  at  the  same  time  most  vulnerable,  points  in  the 
lateral  labyrinth  wall ;  namely — the  prominence  of  the  external  semi- 
circular canal,  the  promontory,  the  oval  and  round  windows ;  however, 
no  part  of  the  osseous  labyrinth  is  entirely  exempt.  Fistulse  of  the 
labyrinth  have  been  found  in  the  region  of  the  external  crus  of  th«^ 
superior  semicircular  canal ;  besides,  cases  have  been  reported  of  the 
inner  labyrinthine  wall  (by  Koerner,  Jansen  and  Habermann)  resulting 
from  long  standing  deep  extraclural  abscess;  while  in  cases  of  necrosis. 
the  loss  of  substance  in  the  labyrinth  capsule  may  extend  in  almost  any 
imaginable  direction. 

ETIOLOGY  AND   PATHOLOGY. 

Since  labyrinth  fistula  is  a  process  secondary  to  middle  ear  suppura- 
tion and  more  especially  that  of  the  chronic  form,  we  must,  in  seeking 
for  the  etiology  of  labyrinth  fistula,  seek  for  the  etiology  of  the  primary 
middle  ear  suppuration  and  especially  for  those  causes  which  tend  to 
produce  chronicity  of  an  already  existing  acute  suppuration. 

I  shall  not  take  the  time  here  to  discuss  all  the  predisposing  and  ac- 
tive causes  of  chronic  middle  ear  suppuration,  but  proceed  immediately 
to  a  brief  discussion  of  the  more  direct  causes  which  tend  to  produce 
fistiilae ;  among  these  may  be  mentioned : 

(1)  Cholesteatoma.    This  is  pre-eminently  the  most  frequent  of  the 
direct  causes  of  labyrinth  fistula.   By  its  growth  that  part  of  the  lateral 
bony  labyrinth  wall  with  which  it  comes  in  direct  contact  is  gradually 
absorbed  until  a  saucer  shaped  fistula  results. 

(2)  Adhesive  bands  between  the  meso-  and  epitympanic  spaces  or 
antrum  leading  to  the  formation  of  closed  or  nearly  closed  cavities 


LABYRINTH  PAPERS.  203 

which  favor  retention  of  secretion  and  pressure.  The  pressure  of  the 
confined  secretion  leads  to  a  destruction  of  the  bone  through  caries  or 
necrosis  or  both  combined. 

(3)  Polyps  and  granulations.    These  may,  by  reason  of  their  pres- 
ence, operate  in  a  similar  manner  as  do  the  adhesions — to  produce  re- 
tention with  pressure  resulting  in  the  destruction  of  the  bone.    Granu- 
lations in  themselves  are  generally  an  evidence  of   deep  seated  bone  in- 
volvement (osteitis)  more  often  of  the  rarifying  type.     Granulations 
occur  frequently  in  the  depressions  about  the  windows  and  lead  event- 
ually to  destruction  of  the  periosteum,  thrombi  of  the  nutrient  vessels 
of  the  underlying  bony  capsule  with  resulting  caries  and  necrosis. 

(4)  Local  tuberculosis.     This    comprises    a    destructive    form    of 
chronic  middle  ear  suppuration  liable  to  result  in  fistula  of  the  labyrinth 
by  reason  of  infiltration  of  the  periosteum  with  subsequent  softening, 
detachment  of  the  periosteum  and  devitalization  of  the  bone. 

(5)  Diabetes.     This  condition   especially   favors  necrosis,   seques- 
tra partial  or  complete  of  the  labyrinth  capsule  being  quite  common. 

(6)  Prolonged  constitutional  diseases  which  lower  the  vitality  of 
the  patient  or  impair  the  power  of  repair. 

(7)  Finally,  unhygienic  surroundings,  poor  nourishment  and  neg- 
lect of  proper  treatment  may  be  mentioned ;  however,  these  last  three 
belong  more  to  the  indirect  or  contributory  causes. 

PATHOLOGY. 

The  microscopic  pathology  of  labyrinth  fistula  will  not  be  discussed 
in  this  paper  for  the  reason  that  ( i )  the  microscopic  pathology  differs 
considerably  in  different  cases,  depending  principally  upon  the  cause; 
(2)  a  sufficient  number  of  cases  have  not  yet  been  studied  to  warrant 
a  thorough  discussion  of  it;  (3)  the  intention  of  the  writer  is  to  dis- 
cuss rather  the  clinical  pathology.  According  to  the  extent  and  depth 
of  the  destructive  process  which  produced  the  fistula,  we  may  find  any 
one  of  the  following  conditions  of  the  membranous  labyrinth  present : 

i,  Normal  and  intact.  2,  Circumscribed  irritative  process  (conges- 
tion). 3,  Circumscribed  destructive  process  (circumscribed  suppura- 
tion or  granulations).  4,  Diffuse  destructive  process  (diffuse  labyrinth 
suppuration).  Chronic  diffuse  plastic  or  obstructive  inflammation  of 
the  membranous  labyrinth  will  not  be  considered  because  (i)  of  its  rare 
association  with  fistula:  (2)  from  the  fact  that  it  does  not  afford  us  a 


204  LABYRINTH  FISTULA. 

distinct  clinicopathologic  type;  (3)  its  discussion  here  would  lead  to 
too  much  confusion  in  the  grasping  of  the  more  frequent  and  funda- 
mental conditions. 

If  one  is  able  to  comprehend  these  four  fundamental  conditions,  he 
will  be  in  a  position  to  work  out  a  clinical  diagnosis  of  the  rarer  complex 
conditions.  These  four  conditions  may  be  considered  the  four  stages 
of  the  same  process  which  follow  each  other  in  the  order  above  men- 
tioned. The  transition  from  one  stage  to  the  next  succeeding  may 
take  place  rapidly  or  slowly,  or  there  may  be  a  prolonged  or  even 
permanent  arrest  of  the  process  at  any  stage.  This  arrest  is  especially 
apt  to  take  place  during  the  third  stage  so  that  the  fourth  stage  may 
never  be  reached.  In  some  cases,  especially  where  the  circumscribed 
destructive  lesion  is  located  in  the  horizontal  semicircular  canal,  the 
spontaneous  arrest  of  the  process  in  the  third  stage  is  very  desirable, 
since  the  patient  retains  fair  hearing.  For  this  reason  our  efforts 
should  be  to  treat  such  cases  with  this  object  in  view. 

These  four  conditions  of  the  membranous  labyrinth,  three  of  which 
are  pathologic,  associated  with  fistula  give  rise  to  four  separate  clinic- 
al pictures.  The  first  three  of  these  conditions  we  are  able  to  diagnose 
and  differentiate,  but  the  fourth  condition  is  really  one  of  the  forms 
of  labyrinth  suppuration  which  is  impossible  of  differentiation  from  the 
other  forms  of  labyrinth  suppuration  without  fistula ;  and  from  the 
standpoint  of  prognosis  and  treatment  the  presence  or  absence  of  a 
fistula  plays  no  important  role. 

In  order  to  better  understand  the  symptoms  and  signs  of  labyrinth 
fistula  when  we  come  to  discuss  them,  it  is  well  that  we  digress  for  the 
present  and  consider  briefly  Ewald's  physiologic  experiments  upon  the 
semicircular  canals  and  Gelle's  test  of  the  acoustic  function. 

Concerning  Ewald's  experiment  you  are  referred  to  the  paper  on 
"Nystagmus." 

The  clinical  application  of  Ewald's  experiment,  but  slightly  modified, 
may  be  applied  as  an  examination  test  for  the  diagnosis  of  fistula  of 
the  static  labyrinth. 

Since  in  most  cases  we  are  unable  by  otoscopic  examination  to  ac- 
tually see  the  fistula  and  apply  compression  and  aspiration  directly  to 
the  membranous  labyrinth,  we  are  compelled  to  do  so  indirectly  by  in- 
creasing and  diminishing  the  atmospheric  pressure  in  the  tympanic 
cavity.  This  is  accomplished  by  a  simple  device  consisting  of  an  olive 


LABYRINTH  PAPERS.  x- 

shapecl  hard  rubber  tip  fitted  on  the  distal  end  of  a  soft  rubber  tube, 
the  proximal  end  of  which  is  attached  to  a  Politzer  balloon,  a  Gelle" 
balloon  or  any  other  suitable  force  and  suction  apparatus. 

The  olive  tip  is  introduced  into  the  external  auditory  canal  air  tight 
and  may  be  held  in  place  by  the  patient ;  the  physician  is  thus  free  to 
manipulate  the  balloon  with  one  hand  and  to  elevate  the  upper  eyelid 
with  the  thumb  of  the  other  hand.  A  positive  fistula  sign  is  manifested 
by  a  pronounced  nystagmus  in  one  direction  when  the  compression  of 
the  balloon  is  made,  and  a  less  pronounced  nystagmus  in  the  opposite 
direction  when  aspiration  is  made.  Again,  both  compression  and  as- 
piration nystagmus  are  accompanied  by  more  or  less  marked  vertigo. 

A  negative  fistula  sign  is  manifested  by  the  absence  of  these  phe- 
nomena. 

The  plane  and  direction  of  the  compression  and  aspiration  nystag- 
mus varies  with  the  location  of  the  fistula.  A  horizontal  nystagmus  to 
the  same  side  by  compression  and  the  opposite  side  by  aspiration  is  the 
most  frequent  and  at  the  same  time  the  most  positive  in- 
dication of  fistula  and  that  of  the  horizontal  semicircular 
canal. 

A  rotatory  nystagmus  to  the  opposite  side  by  compression  and  to  the 
same  side  by  aspiration  indicates  generally  but  not  always  a  fistula  of 
the  superior  semicircular  canal.  At  one  time  Neumann,  and  likewise 
the  writer,  believed  that  this  nystagmus  indicated  a  fistula  of  the  er 
ternal  vestibular  wall  or  loss  of  the  stapes  plate,  but  subsequent  events 
have  not  verified  this  supposition. 

A  rotatory  nystagmus  to  the  same  side  by  compression  and  to  the 
opposite  side  by  aspiration  may  indicate  a  fistula  of  the  external  vesti- 
bular wall  or  of  the  stapes  plate,  but  not  absolutely. 

In  brief  the  most  certain  localizing  compression  and  aspiration  nystag- 
mus is  in  the  case  of  the  external  semicircular  canal.  In  all  other 
cases  of  compression  and  aspiration  nystagmus  we  can  say,  at  most, 
that  the  signs  indicate  fistula  of  the  static  labyrinth  capsule  but  the  ex- 
act location  in  all  cases,  for  the  present  at  least,  remains  more  or  less 
an  open  question. 

The  question  arises :  Is  the  so-called  compression  and  aspiration 
nystagmus  an  infallible  sign  of  fistula?  The  answer  must  be  "no," 
from  the  fact  that  we  find  cases  where  the  sign  is  negative  in  spite  of 
the  presence  of  fistula,  and  on  the  other  hand  we  find  cases  where  the 


206  LABYRINTH   FISTULA. 

sign  is  positive  without  the  actual  presence  of  a  fistula.  The  reasons 
for  these  discrepancies  have  been  pointed  out  by  Alexander  and  La- 
salle,  "Ueber  den  durch  Luftdruckveranderungcn  auslosbaren  Xystag- 
rnus  und  das  Fistelsymptom,  \\'iener  klin.  Rundschen,  1908,  and  by  the 
writer.  The  reasons  are  as  follows :  — 

I — Negative  fistula  sign  with  positive  fistula  may  be  found : 

(a)  In  cases  of  labyrinth  destruction  (suppuration)  ;  since  the  laby- 
rinth is  nonreactive  the  sign  must  be  negative. 

(b)  In  cases  of  obstruction  from  polyps,  adhesions  or  large  choles- 
teatoma  plugging  up  the  fistula,  compression  of  the  membranous  laby- 
rinth is  quite  impossible. 

(c)  In  cases  of  large  dilated  Eustachian  tubes,  the  air  escapes  thru 
the  open  tube  and  makes  impossible  any  increase  of  atmospheric  press- 
ure within  the  middle  ear  spaces. 

II — Positive  fistula  sign  with  negative  fistula  may  be  found : 

(a)  In  cases  of  acute  middle  ear  inflammation  (frequently  observed 
by  the  writer).     The  explanation  offered  is  that  of  a  combination  of 
factors ;  first,  the  Eustachian  tube  is  closed  by  inflammatory  swelling ; 
second,  because  of  this  closure  the  secretion  is  more  confined  to  the 
middle  ear  and  cannot  escape  thru  the  tube ;  third,  compression  of  the 
secretion  acts  as  a  hydraulic  pressure  which  is  necessarily  greater  than 
pneumatic  pressure;  fourth,  the  ligament  surrounding  the  stapes   is 
more  mobile  because  of  the  presence  of  secretion  than  it  normally  is 
when  there  is  no  secretion  in  the  middle  ear  space. 

(b)  In  case  of  chronic  middle  ear  suppuration  with  loss  of  the  ham- 
mer and  incus  (observation  by  Alexander). 

Notwithstanding  the  fallibility  of  the  fistula  sign,  the  presence  of  it, 
especially  when  marked,  is  strongly  suggestive  of  labyrinth  fistula. 

GELLE'S  TEST. 

Gelle's  test  was  originally  intended  as  a  test  for  the  determination  of 
ankylosis  of  the  stapes  in  the  oval  window  in  cases  of  otosclerosis. 
The  test  is  made  with  an  apparatus  similar  to  that  used  for  the  de- 
termination of  compression  and  aspiration  nystagmus  (described  above) 
with  the  exception  that  compression  only  is  used. 

Normally  compression  of  air  in  the  external  canal  is  communicated 
to  the  stapes,  which  is  forced  inward  and  held  so  by  the  pressure  from 
the  tympanic  side.  The  effect  of  the  forcible  pressure  inward  of  the 


LABYRINTH  PAPERS.  207 

stapes  plate  is  to  produce  impairment  of  hearing  of  a  type  correspond- 
ing to  disease  of  the  perceiving  apparatus ;  namely,  Rinne  positive  with 
shortened  bone  conduction.  Weber  lateralized  to  the  opposite  side, 
etc.  This  effect  upon  the  normal  ear  is  known  as  a  positive  Gelle 
sign. 

In  cases  of  otosclerosis  the  compression  of  air  in  the  canal  produces 
no  effect  upon  the  hearing,  since  the  stapes  plate  is  ankylosed  in  the 
oval  window.  This  negative  effect  is  designated  "negative  Gelle  sign." 

In  cases  of  fistula  or  abnormally  loose  and  movable  stapes,  instead  of 
the  normally  moderate  positive  Gelle  we  find  abnormally  p  r  o- 
n  o  u  n  c  e  d  positive  Gelle  sign,  which  we  may  term  a  fistula  sign  of  the 
acoustic  labyrinth.  According  to  Politzer,  in  cases  of  pathologic  con- 
dition of  the  membranous  labyrinth  the  positive  Gelle  sign  is  likely  to 
be  more  pronounced  than  in  those  cases  with  normal  membranous  laby- 
rinth. 

The  principle  of  the  Gelle  test  may  be  applied  in  one  of  two  WHY-; 
First — after  inserting  the  olive  tip  air  tight  in  the  canal,  apply  the 
handle  of  a  vibrating  tuning  fork  (Politzer  middle  tone)  to  the  ba^. 
\Yhen  compressing  the  bag  with  the  hand  the  pressure  of  air  in  the  ear 
is  increased  and  upon  relaxation  the  pressure  is  diminished.  With  the 
normal  ear  the  fork  is  heard  less  distinctly  during  compression  than 
during  relaxation :  this  is  recognized  as  a  normally  positive  Gelle.  In 
the  case  of  otosclerosis.  where  the  foot  plate  of  the  stirrup  is  ankylosed 
in  the  oval  window,  the  compression  of  air  does  not  produce  the  same 
degree  of  diminution  of  hearing  as  the  normal ;  this  is  recognized  as  a 
negative  Gelle. 

In  the  case  of  abnormally  loose  stapes  or  where  a  fistula  exists  in  the 
region  of  the  vestibule,  the  diminution  of  hearing  is  greater  than 
normal :  this  is  recognized  as  an  abnormally  positive  Gelle. 

Secondlv — Since  compression  of  air  in  the  ear  presses  the  foot- 
plate of  the  stapes  inward  in  the  oval  window  an  experimental  inner 
ear  disease  is  produced  in  normal  individuals,  therefore  it  follows  that 
the  vibrating  fork  held  to  the  mastoid  is  heard  less  distinctly  or  not  at 
all  during  the  compression  of  air  in  the  ear  and  heard  again  during 
relaxation. 

In  the  case  of  ankylosis  of  the  foot-plate  in  the  oval  window  the 
diminution  of  bone  conduction  is  less  evident  than  normal,  and  in  the 
case  of  abnormally  1<  ><  »L-  stapes  plate  or  in  case  of  fistula  this  diminu- 
tion of  bone  conduction  is  more  evident  than  normal. 


208  LABYRIXTH  FISTULA. 

By  a  comparison  with  a  sufficient  number  of  normal  cases  one  learns 
to  recognize  the  difference  between  the  normally  positive  Gelle  and 
the  abnormally  positive  as  found  in  fistula  of  the  acoustic  labyrinth. 

SYMPTOMS  AND  SIGN'S  OF  LABYRINTH  FISTULA. 

I — With  normal  and  intact  membranous  labyrinth. 

1.  By  otoscopic  examination  evidence  of  middle  ear  suppuration, 
i.  e.,  partial  or  complete  destruction  of  the  tympanic  membrane,  dis- 
charge, etc. 

2.  Impairment  of  hearing  of  the  type  belonging  to  disease  of  the 
conducting  apparatus :  Weber  to  diseased  side,  lengthened  bone  con- 
duction, negative  Rinne,  etc. : 

3.  Absence  of  acoustic  and  static  labyrinth  symptoms  including  tin- 
nitus, vertigo,  nystagmus  and  equilibrium  disturbances 

4.  Normal  reactions  of  static  labyrinth  to  turning,  caloric  and  gal- 
vanic irritations. 

5.  Positive  fistula  sign. 

(a)  If  the  fistula  is  located  in  the  region  of  the  static  labyrinth,  we 
find  marked  compression  and  aspiration  nystagmus  associated   with 
vertigo  (making  due  allowance  for  the  exceptions  already  mentioned). 

(b)  If  the  fistula  is  located  in  the  region  of  the  acoustic  labyrinth 
we  find  a  very  positive  Gelle  sign.     In  some  rare  cases  with  a  single 
fistula  located  in  the  region  of  the  vestibule  we  find  a  combination  of 
these  two  fistula  signs. 

II — Labyrinth  fistula  with  circumscribed  irritative  process  of  the 
membranous  labyrinth. 

According  to  the  location  of  the  fistula  there  may  be  present  one  of 
two  distinct  and  separate  pictures ;  they  are : 

(A)  In  case  of  fistula  of  the  acoustic  labyrinth  with  irritative  pro- 
cess of  corresponding  part  of  the  membranous  labyrinth : 

1.  By  otoscopic  examination  evidence  of  middle  ear  suppuration  as 
in  other  cases  of  labyrinth  fistula. 

2.  Impairment  of  hearing  of  the  type  belonging  to  disease  of  the 
conducting  apparatus  with  a  slight  element  belonging  to  disease  of  the 
perceiving  apparatus. 

3.  Tinnitus  corresponding  in  pitch  to  the  location  in  the  cochlea 
which  is  involved. 

4.  Absence  of  static  labyrinth  symptoms ;  vertigo,  nystagmus,  equi- 
librium disturbance. 


LABYRINTH  PAPERS.  209 

5.  Reaction  of  the  static  labyrinth  normal. 

6.  Very  positive  Gelle  symptom.     In  other  words,  by  compression 
abnormally  marked  diminution  of  hearing,  especially  thru  the  bone. 

(B)  In  case  of  fistula  of  the  static  labyrinth  with  irritative  process  ot 
the  corresponding  part  of  the  membranous  labyrinth  we  find : 

1.  By  otoscopic  examination,  evidence  of  middle  ear  suppuration  as 
in  other  cases. 

2.  Impairment  of  hearing  of  the  type  belonging  to  disease  of  the 
conducting  apparatus. 

3.  Absence  of  acoustic  labyrinth  symptoms,  or  more  concisely  speak- 
ing, there  is  no  tinnitus. 

4.  Positive  static  labyrinth  symptoms : 

(a)  Vertigo  pronounced  or  slight,  depending  upon  the  degree  and 
extent  of  the  process  and  characteristically  aggravated  by  rapid  move- 
ments of  the  head,  no  matter  whether  they  are  made  actively  by  the 
patient  or  passively  by  the  surgeon. 

(b)  Nystagmus,  rotatory,  horizontal  or  mixed,  to  the  diseased 
side.     The  nystagmus  may  be  constant  or  intermittent  and  like  the 
vertigo  can  be  excited  by  the  surgeon  making  rapid  passive  movements 
of  the  patient's  head. 

(c)  Equilibrium  disturbances  which  have  been  amply  described  in 
the  series  of  papers  upon  labyrinth  suppuration  and  elsewhere  and  can 
be  easily  determined  by  Stein's,  Alexander's  and  Mackenzie's  tests.* 

5.  Reactions  of  static  labyrinth    increased    upon  the  diseased 
side  to  turning  and  to  the  caloric  and  galvanic  irritations. 

6.  Positive  fistula  sign;  that  is,  marked  compression  and  aspiration 
nystagmus. 

Ill — Labyrinth  fistula  with  circumscribed  destructive  process  in  the 
membranous  labyrinth,  like  the  former  condition,  may  present  one  of 
two  distinct  clinical  pictures  according  to  the  location  of  the  fistula. 
They  are : 

(A)  In  case  of  fistula  of  the  acoustic  labyrinth  with  destructive  pro- 
cess of  the  corresponding  part  of  the  membranous  labyrinth,  the  symp- 
toms and  signs  are: 

1.  By  otoscopic  examination,  evidence  of  middle  ear  suppuration  as 
before. 

2.  General  impairment  of  hearing  of  the  type  belonging  to  disease 
of  the  conduction  apparatus,  together  with  absolute  deafness  for  certain 


2io  LABYRINTH  FISTULA. 

tones  corresponding  to  the  area  of  destruction.  In  other  words — 
single  or  multiple  scotoma.  This  latter  circumscribed  deafness  is  of 
the  type  belonging  to  affections  of  the  perceiving  apparatus.  These 
may  be  best  ascertained  by  the  use  of  Bezold's  continuous  chain  of 
forks. 

3.  Tinnitus  is  present  during  the  active  stage  since  there  is  a  zone  of 
irritation  surrounding  the  area  of  destruction.     In  a  very  late  stage 
tinnitus  may  be  absent. 

4.  Absence  of  static  labyrinth  symptoms. 

5.  Static     labyrinth     reacts     normally    to    the    usual    examination 
methods. 

6.  Gelle's  sign  may  be  positive  or  negative,  depending  upon  the  size 
of  the  fistula  and  the  extent  and  character  of  the  destruction. 

In  those  cases  where  it  is  possible  to  produce  compression  of  the 
endo-  or  perilymph  beyond  the  areas  of  the  destructive  process,  the 
Gelle  sign  would  be  proportionately  positive ;  on  the  other  hand,  in 
those  cases  where  extensive  granulations  or  organized  exudate  within 
the  labyrinth  prevent  the  possibility  of  compression  of  the  endo-  and 
perilymph  beyond  the  area  of  the  destructive  process,  the  Gelle  sign 
must  be  negative. 

(B)  In  cases  of  fistula  of  the  static  labyrinth  with  destructive  pro- 
cess of  the  corresponding  part  of  the  membranous  labyrinth,  the  symp- 
toms and  signs  are : 

1.  By  otoscopic  examination,  evidence  of  middle  ear  suppuration  as 
before. 

2.  Impairment  of  hearing  of  the  type  belonging  to  disease  of  the 
conducting  apparatus. 

3.  Absence  of  tinnitus. 

4.  Positive  static  labyrinth  symptoms:     (a)  vertigo  is  always  pres- 
ent in  acute  cases,  absent  in  late  cases.     The  vertigo  is  aggravated  by 
rapid  head  movements ;  (b)  nystagmus,  rotatory,  horizontal  or  mixed, 
it    the    unaffected    side.     The  nystagmus  is  more  constant,  but 
rapidly  diminishes  in  intensity  and    may    eventually  disappear ;   (c) 
•equilibrium  disturbances  are  pronounced  in  early  stages  and  but  slight 
in  late  stages. 


*Klinische  Untersuchungen  ueber  die  Labyrinthaeren  Gleichgewichtsstoerungen 
mit  besonderer  Bereuck  der  allegemeiner  Pruefungsmethoden  und  des  Gonio- 
meters. Arch.  f.  Ohrcnh.  Bd.  78,  1009. 


LABYRINTH  PAPERS.  211 

5.  Reactions  of  static  labyrinth  partially  or  completely  lost  upon  the 
affected  side,  dependent  upon  the  extent  of  the  area  of  destruction. 

6.  Fistula  sign,  that  is,  compression  and  aspiration  nystagmus,  ab- 
sent. 

IV — Labyrinth  fistula  with  diffuse  destructive  process  of  the  laby- 
rinth. The  symptoms  and  signs  in  this  condition  are  the  same  as  those 
of  labyrinth  suppuration,  and  briefly  are : 

1.  Otoscopic  examination  shows  evidence  of  middle  ear  suppura- 
tion. 

2.  Complete  loss  of  hearing. 

3.  Absence  of  tinnitus. 

4.  Positive    static    labyrinth    symptoms — vertigo,  nystagmus    and 
equilibrium  disturbance   (see  former  papers  upon  labyrinth  suppura- 
tion). 

5.  Negative  reactions  from  the  static  labyrinth  of  the  affected  side. 

6.  Fistula  sign  negative. 

PROGNOSIS  AND  TREATMENT. 

The  prognosis  and  treatment  is  too  large  a  subject  to  take  up  at  the 
present  time,  besides  the  subject  has  already  been  considered  more  or 
less  in  a  former  paper  upon  the  Prognosis  and  Treatment  of  Labyrinth 
Suppuration. 


REPORT  AND  DISCUSSION  OF  A  CASE  OF  LABYRINTH 

FISTULA. 

WHEN  comparing  the  history,  findings  and  ultimate  results 
of  the  present  case  with  other  similar  cases  of  labyrinth 
fistula,  treated  after  the  same  manner,  the  writer  finds 
so  much  similarity  that  he  could  just  as  well  have  selected  any  one 
of  the  other  cases. 

THE  CASE.* 

Name—R.  W. 

Age — 27  years. 

Occupation — Clerk. 

Diagnosis  (made  prior  to  and  substantiated  at  the  time  of  opera- 
tion)— Otitis  Media  Suppurativa  Chronica  Sinistra  et  Cholesteatoma 
et  Fistula  Labyrinthi  (external  semicircular  canal). 

Treatment — Mastoid  operation  after  the  Zaufall  method,  removal 
of  the  cholesteatoma  and  plastic  after  Panse. 

History — Discharge  from  the  left  ear  since  third  year  of  life.  Pa- 
tient is  unable  to  recall  how  the  discharge  first  began  or  whether  it 
was  preceded  by  any  other  disease.  From  the  third  year  until  two 
years  ago  the  discharge  continued  without  interruption.  Two  months 
ago  (June,  1907)  the  left  ear  started  to  discharge  again.  Two  weeks 
ago  the  patient  experienced  dizziness  for  the  first  time.  Every  move- 
ment of  the  body  and  walking  brings  on  an  attack  of  dizziness  which 
prompts  the  patient  to  seek  a  quiet  position  of  the  body,  when  the 
dizziness  becomes  less  intense  or  disappears  altogether. 

With  dizziness  the  patient  experiences  a  sensation  of  turning  and 
swaying.  When  questioned,  he  disclaims  any  sensation  of  movement 
of  external  objects.  The  patient  has  been  treated  by  a  physician  prior 
to  his  admission  to  the  hospital.  He  comes  for  treatment  on  account 
of  dizziness,  impairment  of  hearing  and  profuse  discharge  from  the 
left  ear. 


*I  am  indebted  to  Professor  Alexander,  of  the  Vienna  Polyclinic  Hospital,  for 
the  opportunity  allowed  me  to  study  this  along  with  the  other  similar  cases.  It 
was  my  privilege,  while  acting  as  Zimmerarzt  under  him,  to  examine,  study  and 
write  up  the  cases  before  operation,  to  take  part  in  the  operations  and  to  look 
after  the  after-treatment. 


LABYRINTH  PAPERS. 


OTOSCOPIC  FINDINGS. 

Right  ear  normal. 

Left  Ear — Profuse  and  very  offensive,  dirty  gray  colored,  purulent 
discharge  which  when  wiped  away  shows  the  external  canal  to  be  nor- 
mal. Complete  destruction  of  the  tympanic  membrane.  Remnant  of 
the  hammer  handle  still  present.  Large  polyp  behind  the  short  process 
of  the  hammer.  Granulations  in  the  hypotympanum  which  bleed  read- 
ily. Typical  cholesteatoma  visible.  Mastoid  process  not  sensitive  and 
periosteum  not  thickened. 

FUNCTIONAL   EXAM  I  NATION. 


1 
Right 

Left 

12  meters, 

4  Conv.  voice 

.    .      i  mete. 

12  meters, 

•f  Whisp.  voice  .  . 

.  Ad.  conchr 

12  meters, 

4  Acumeter   . 

.    .  Ad.  conch 

Weber  >  . 

.    .  To  the  left 

Normal  . 

.    .  Schwabach  .    . 

.    .  Shortened 

4.  . 

Rinne"  .    . 



Normal 

.  c,. 

Shortened 

Normal 

.        .C4, 

.    .  Shortened 

/ 

4- 

Watch  on  mastoid 

i    •   •    •   • 

t 

» 

4 

s 

SPONTANEOUS   NYSTAGMUS. 

Slight  nystagmus  to  the  right  when  looking  to  the  extreme  right 
and  to  the  left  when  looking  to  the  extreme  left;  but  to  neither  side 
more  marked  than  to  the  other. 

CALORIC   NYSTAGMUS. 

By  syringing  the  left  ear  with  cold  water  with  the  head  in  the  erect 
position  the  patient  exhibits  rotatory  nystagmus  to  the  right. 

GALVANIC  NYSTAGMUS. 

Was  not  examined  for  at  this  sitting. 

TURNING   NYSTAGMUS. 

After  ten  turnings  to  the  left  (3600°)  with  head  inclined  forward 


2i4  A  CASE  OF  LABYRINTH  FISTULA. 

90°  the  patient  manifests  a  bilateral  rotatory  nystagmus  to  the  right, 
when  looking  straight  ahead,  for  a  period  of  20  seconds. 

After  ten  turnings  to  the  right  (3600°)  with  head  inclined  forward 
90°  the  patient  manifests  bilateral  rotatory  nystagmus  to  the  left,  last- 
ing for  a  period  of  20  seconds. 

EQUILIBRIUM. 

At  the  time  of  this  examination  (August  26,  1907)  there  was  no 
evidence  of  equilibrium  disturbances  by  the  usual  tests,  including  that 
made  on  the  Alexander-Stein  goniometer. 

Three  days  later  (August  29)  after  an  accident  which  occurred 
during  the  local  treatment,  to  be  described  later,  the  patient  showed 
positive  signs  of  equilibrium  disturbances  by  all  tests  as  follows: — 

Rhomberg  positive,  gait  forward  and  backward  broad  and  uncertain 
hopping  on  one  foot  quite  impossible.  The  Alexander-Stein  gonio 
meter  test  showed  quite  evident  disturbances,  as  follows : — 

With  eyes  closed  and  face  forward  the  patient  tends  to  topple  ovei 
with  an  elevation  of  14°,  with  face  backward  11°,  with  face  to  tht 
right  9°  and  with  face  to  the  left  10°. 

For  reasons  stated  below  the  author  on  this  same  date  made  tht 
test  for  labyrinth  fistula ;  as  a  result,  compression  and  aspiration 
nystagmus  or  the  so-called  fistula  symptom  was  found  to  be  positive. 
Upon  applying  compression  of  air  in  the  external  canal  of  the  left 
ear  the  patient  manifests  a  pronounced  horizontal  nystagmus  to  the 
left  and  upon  applying  suction,  a  pronounced  horizontal  nystagmus  to 
the  right.  The  compression  nystagmus  to  the  left  is  somewhat  more 
pronounced  than  the  aspiration  nystagmus  to  the  right. 

The  examination  for  compression  and  aspiration  nystagmus  was 
not  generally  made  prior  to  this  time,  but  has  been  quite  universally 
since.  This  case  appeared  at  a  time  when  aurists  were  beginning  to 
recognize  the  importance  of  the  symptom. 

OPERATION. 

The  case  was  operated  by  Professor  Alexander,  August  29th,  1907, 
under  general  narcosis  with  Billroth's  mixture;  operation  lasting  25 
minutes.  Operation  as  follows : — Typical  retro-auricular  incision  from 
4  to  5  cm.  long.  Laying  free  of  the  mastoid  process.  Chiseling  open 
the  same  to  the  antrum  which  was  filled  with  a  cholesteatomatous  mass. 
Removal  of  the  cholesteatoma  and  curettement  of  the  matrix.  Thoro 


LABYRINTH  PAPERS.  215 

removal  of  all  granulations  in  the  middle  ear  spaces.  On  the  promi- 
nence of  the  external  semicircular  canal  a  3mm.  long  oval  shaped, 
fistula  was  found.  The  dura  of  the  posterior  fossa  was  exposed  for  an 
area  about  the  size  of  a  5  cent  piece.  The  operation  was  completed 
after  the  method  of  Zauf all ;  plastic  after  Panse ;  wound  dressing  with 
iodoform  gauze  and  bandage. 

August  29th.  Evening  of  same  day.  Patient  vomited  considerably, 
pronounced  vertigo. 

August  3Oth.  Patient  vomited  often,  has  pronounced  vertigo, 
rotatory  nystagmus  to  the  right  when  looking  straight  ahead. 

August  31.  Patient  feels  generally  better,  has  not  vomited.  Vertigo 
has  become  less  severe.  Rotatory  nystagmus  to  the  right  when  look- 
ing straight  ahead,  but  less  pronounced  than  yesterday. 

September  ist.    No  vertigo.    Rotatory  nystagmus  to  the  right. 

September  2d.     No  vertigo.     Rotatory  nystagmus  to  the  right. 

September  3d.  No  vertigo.  Rotatory  nystagmus  to  the  right.  Slight 
facial  palsy  on  left  side  involving  all  branches  of  the  7th  nerve. 

September  5th.  Change  of  dressings.  No  vertigo.  Rotatory 
nystagmus  to  the  right  present,  but  diminishing  in  intensity.  Facial 
palsy  more  pronounced,  patient  can  barely  whistle  and  raises  the  left 
angle  of  his  mouth  poorly.  Can  close  left  eye  but  incompletely. 

September  Qth.  Change  of  dressings.  No  vertigo.  Rotatory 
nystagmus  to  the  right  less  pronounced.  Facial  palsy  unchanged.  Pa- 
tient feels  the  slightest  degree  of  vertigo  when  walking.  Was  dis- 
charged from  the  hospital  and  made  an  ambulatory  patient  to  report 
for  further  treatment  and  observation. 

September  loth.  Change  of  dressings.  Vertigo  is  only  present  when 
making  quick  movements.  Rotatory  nystagmus  to  the  right.  Facial 
palsy  unchanged.  Examination  of  left  ear  with  3  meter  speaking  tube 
whispered  words  heard  without  failure. 

September  I2th.  Change  of  dressings.  Facial  palsy  less  distinct. 
Patient  can  close  left  eye.  Rotatory  nystagmus  to  the  right  continues. 
Speaking  tube-whispered  words  heard  without  failure. 

September  i/th.  Change  of  dressings.  Facial  palsy  about  the  same 
as  last  examination.  Rotatory  nystagmus  to  the  right.  When  cold 
water  is  syringed  into  left  ear  the  nystagmus  is  unaffected  (not  in- 
creased). 

September  i8th.  Change  of  dressings.  Retro-auricular  wound 
much  smaller.  Facial  palsy  unchanged  since  last  examination.  Cold 


2l6 


A  CASE  OF  LABYRINTH  FISTULA. 


water  in  left  ear  produces  no  alteration  of  the  very  slight  degree  of 
rotatory  nystagmus  to  the  right. 

After  ten  turnings  to  the  left  with  head  inclined  forward,  pronounced 
rotatory  nystagmus  to  the  right  lasting  twenty  seconds. 

After  ten  turnings  to  the  right  with  head  inclined  forward,  rotatory 
nystagmus  to  the  left  lasting  ten  seconds. 

Speaking  tube,  whispered  voice  heard  without  failure. 

September  29th.  Redressing.  Facial  palsy  improved.  Spontaneous 
rotatory  nystagmus  to  the  right  when  looking  to  the  right.  No  nystag- 
mus to  the  right  or  left  when  looking  to  the  left.  Same  reactions  to 
turning  as  on  the  i8th.  Speaking  tube,  whispered  voice  heard  with- 
out failure. 

October  loth.  Facial  palsy  decidedly  better,  other  findings  about 
the  same  as  last  examination.  Wound  closed  and  all  discharge  from 
left  ear  has  ceased. 

Patient  was  told  to  report  at  wider  intervals. 

A  complete  functional  re-examination  was  made  December  loth 
which  gave  the  following  results : 

DECEMBER    IOTH,    1907. 


Right  Left 

12  meters,  -j-  Conv.  voice  ....  2%  meters 
12  meters,  -(-  Whisp  voice    .    .    .    .  y$  meter 

12  meters,  -f  Acumeter o 

Weber  ....  Not  lateralized 
Slightly  short,  Schwabach   .    .    .  Very  short 

-f Riling - 

Normal  .    .        .    .   C1,  o 

Normal  ...  c4, o 

Normal  ....        A,    .           .    .        .    .  o 
+  •    •    •    •  Watch  on  mastoid 


SPONTANEOUS   NYSTAGMUS. 


When  looking  to  the  right, 
bilateral  rotatory  rhythmic 
nystagmus  to  the  right.  Also  less 
marked  rotatory  nystagmus  to 
the  right  when  looking  straight 
ahead. 


Xo  nystagmus  to  the  left  when 
looking  to  the  left. 


LABYRINTH  PAPERS.  217 


CALORIC    NYSTAGMUS. 

Negative,  i.  e.,  syringing  the 
left  ear  with  large  quantities  of 
cold  water  does  not  increase  the 
existing  spontaneous  nystagmus 
to  the  right. 

AFTER-TURNING    NYSTAGMUS. 

After  ten  turnings  to  the  left  After    ten    turnings    to    the 

with  head  erect  and  with  opaque  right  with  head  erect  and  with 

glasses    before    the    eyes,    hori-  opaque  glasses  before  the  eyes, 

zontal   nystagmus   to   the   right  horizontal  nystagmus  to  the  left 

lasting  35  seconds.  lasting  12  seconds. 

After  ten  turnings  to  the  left  After    ten    turnings    to    the 

with  head  inclined  forward,  ro-  right    with    head    inclined    for- 

tatory   nystagmus   to   the   right  ward,  rotatory  nystagmus  to  the 

lasting  19  seconds.  left  lasting  n  seconds. 

GALVANIC  NYSTAGMUS. 

Kathode      4      ma.      rotatory  Kathode  10  ma.  no  effect, 

nystagmus  to  right  increased.  Anode  4  ma.,  rotatory  nystag- 

Anode  10  ma.  no  effect.  mus  to  right  increased  (?). 

THREE   METER  SPEAKING  TUBE. 

Conversational  voice  without 
failure. 

COMPRESSION   AND  ASPIRATION    NYSTAGMUS. 

Negative. 

EQUILIBRIUM. 

Positive  evidence  of  equilibrium  disturbances  as  shown  by  positive 
Rhomberg.  Wide  and  uncertain  gait  both  forward  and  backward, 
also  side  stepping  and  hopping  on  one  foot  less  certain  than  normal. 


2i8  A  CASE  OF  LABYRINTH  FISTULA. 


ON   THE  GONIOMETER. 

With  open  eyes:  With  closed  eyes: 

Face  forward  26°.  Face  forward  14°. 

Face  backward  23°.  Face  backward  11°. 

Face  to  right  19°.  Face  to  right  10°. 

Face  to  left  18°.  Face  to  left  9°. 

Patellar  reflexes  normal  as  are  also  other  deep  reflexes.     Vision 
normal,  pupils  react  promptly  to  light,  accommodation  and  convergence. 
Patient's  intelligence  normal. 

DISCUSSION    OF  THE   CASE. 

The  history  is  that  of  a  chronic  middle  ear  suppuration.  The  fact 
that  the  discharge  was  intermittent  suggests  a  cholesteatoma.  The 
history  of  dizziness  with  the  subjective  sensation  of_  turning  aggra- 
vated by  active  movements,  ameliorated  by  keeping  quiet,  in  the  course 
of  chronic  middle  ear  discharge  should  direct  our  attention  imme- 
diately to  the  inner  ear. 

The  dizziness,  ^however,  does  not  tell  us  the  exact  character  of  the 
lesion  within  the  inner  ear,  for  it  may  be  due  to  one  of  several  clinical 
conditions,  an  irritative  lesion,  circumscribed  or  general,  or  a  de- 
structive lesion,  circumscribed  or  general. 

The  Otoscopic  Findings.  The  offensive  discharge  in  spite  of  the 
treatment,  which  he  had  prior  to  admission  to  the  hospital,  suggests  a 
cholesteatoma.  The  complete  destruction  of  the  membrane  may  sug- 
gest either  chronicity  or  marked  virulence  of  the  original  infection. 
It  more  often  points  to  the  latter  for  in  those  cases  of  suppuration 
following  scarlet  fever  we  frequently  find  complete  destruction  of  the 
membrane  early.  Again  complete  destruction  of  the  membrane  is  a 
most  favorable  condition  for  the  development  of  a  cholesteatoma,  which 
by  the  way  was  present  too  in  this  case  (see  paper  by  author — "Zur 
Clinischen  Diagnostik  des  Mittelohrchlesteatome,"  Monatsshr  fur 
ohrenheilk,  1908).  A  part  of  the  cholesteatoma  was  visible  by  otoscopic 
examination,  presenting  a  glistening,  pearly  white,  smooth  surface. 

The  granulations,  bleeding  readily,  suggest  bone  involvement  and 
they  are  apt  to  be  found  in  conjunction  with  cholesteatoma. 

Functional  Examination.  The  right  ear  showed  normal  hearing 
function.  The  rooms  in  the  hospital  were  not  ideal  for  determining 


LABYRINTH  PAPERS.  219 

hearing  distances,  so  the  figures  are  lower  than  they  would  otherwise 
have  been. 

The  left  ear  showed  the  hearing  to  be  greatly  reduced.  Lateraliza- 
tion  of  the  tuning  fork  to  the  left  points  to  middle  ear  affection ;  but 
since  the  bone  conduction  on  the  left  mastoid  was  shortened  we  have 
a  finding  which  points  to  inner  ear  affection.  The  Rinne  was  nega- 
tive, which,  when  combined  with  shortened  bone  conduction,  indicates 
middle  ear  disease  with  secondary  inner  ear  involvement. 

That  Cx  was  shortened  points  to  middle  ear  disease. 

That  c4  was  shortened  points  to  inner  ear  disease. 

Watch  on  mastoid  was  heard  on  the  normal  side  but  not  on  the 
affected  side,  which  fact  points  to  disease  of  the  inner  ear  of  the  af- 
fected side. 

That  the  spontaneous,  rhythmic  nystagmus  was  present  to  the  left 
when  looking  strongly  to  the  left  and  to  the  right  when  looking  strongly 
to  the  right,  but  to  neither  side  more  marked  than  to  the  other  does 
not  suggest  disease  of  the  inner  ear  or  at  least  of  the  membranous 
part.  On  this  point  I  wish  to  emphasize  the  fact  that  normal  indi- 
viduals when  looking  intently  enough  to  the  right  or  left  side  will 
manifest  a  rhythmic  nystagmus  in  the  particular  direction  toward  which 
they  are  looking.  This  is  purely  physiologic.  Again,  it  is  possible  for 
the  osseous  labyrinth  to  be  considerably  involved,  especially  in  cases 
of  fistula,  before  the  membranous  labyrinth  shows  any  physical  or 
clinical  signs  of  involvement. 

But  how  are  we  to  explain  the  apparently  contradictory  facts, 
namely,  the  absence  of  spontaneous  nystagmus  and  the  presence  of 
vertigo  (mentioned  in  the  history)  ?  The  vertigo  mentioned  in  the  his- 
tory was  evidently  due  to  causes  which  were  transient  (circumscribed 
congestion)  and  not  present  at  the  time  of  the  examination  on  the 
26th  of  August. 

That  this  was  the  case  is  further  borne  out  by  the  results  obtained 
thru  turning. 

The  after-turning  nystagmus  was  of  equal  duration  to  the  two  sides 
and  approximately  normal  (20  seconds).  Had  the  patient  suffered 
an  irritative  lesion  at  the  time  of  the  examination  he  would  have  mani- 
fested a  longer  duration  of  nystagmus  to  the  affected  side.  Had  he 
suffered  a  destructive  lesion  he  would  have  manifested  a  much  shorter 
duration  of  the  nystagmus  to  the  affected  side. 

The  Caloric  Reaction  made  with  cold  water  douched  into 


220  A  CASE  OF  LABYRIXTH  FISTULA. 

the  left  middle  ear  cavity  indicated  that  the  inner  ear  was  reactive  and 
not  destroyed,  for  the  patient  showed  a  pronounced  rotatory  nystagmus 
to  the  opposite  (right)  side. 

The  Galvanic  Nystagmus  was  not  examined  at  this  time 
for  I  had  not  yet  worked  the  subjeft  up  to  the  point  that  I  had  later. 

We  come  next  to  a  very  important  sign  in  the  diagnosis  of  labyrin- 
thine fistula,  which  was  present  in  this  case,  namely,  compression  and 
aspiration  nystagmus  called  also  the  fistula  sign. 

Prior  to  this  time  it  was  not  the  routine  practice  to  examine  every 
case  for  the  presence  or  absence  of  this  sign,  however  it  became  so 
immediately  afterwards. 

In  this  case  the  sign  was  found  quite  accidentally.  The  patient  after 
waiting  three  days  in  the  hospital  for  his  turn  to  be  operated,  began 
to  grow  anxious  because  of  the  postponement  of  his  operation,  which 
was  made  necessary  on  account  of  a  rush  of  other  cases  demanding 
more  immediate  attention.  In  order  to  pacify  and  hold  the  patient  in 
the  hospital  for  another  day  it  was  necessary  to  do  something.  Ac- 
cordingly it  was  agreed  to  remove  a  polyp  with  the  snare.  Upon  en- 
gaging the  polyp,  using  the  average  amount  of  pressure  necessary  to 
reach  as  near  the  base  as  possible,  the  patient  suddenly  cried  out  in 
terror,  extended  both  arms,  grasped  the  table  with  one  hand  and  an 
assistant  with  the  other  while  his  face  took  on  a  wild  expression  with 
widely  open  eyes,  and  sweat  flowed  freely.  He  was  a  very  sick  look- 
ing man  for  a  short  time.  I  recognized  it  immediately  as  a  severe  at- 
tack of  vertigo,  the  result  of  pressure  on  some  part  of  the  lateral  laby- 
rinthine wall  where  the  capsule  was  defective. 

After  waiting  several  minutes  until  the  patient  had  become  quiet 
and  normal  again  I  attempted  to  demonstrate  the  presence  of  com- 
pression and  aspiration  nystagmus.  Upon  applying  pressure  the  eyes 
made  quick  horizontal  movements  to  the  left  (same)  side,  of  about  6 
mm.  excursion,  occurring  at  an  approximate  rapidity  of  three  com- 
plete excursions  for  each  second  of  time.  Upon  releasing  the  pressure 
and  using  gentle  aspiration,  the  nystagmus  changed  to  that  of  hori- 
zontal to  the  right  of  somewhat  shorter  excursion  than  it  had  been  to 
the  left.  The  character  and  direction  of  the  nystagmus  (remembering 
Ewald's  experiment)  established  in  the  writer's  mind  the  diagnosis  of 
fistula  of  the  osseous  horizontal  (external)  s  e  m  i  c  i  r  - 
cularcanal  with  the  membranous  canal  intact,  which 
diagnosis  was  corroborated  at  the  time  of  the  operation. 


LABYRINTH  PAPERS.  221 

After  waiting  an  hour  the  patient  was  examined  on  the  goniometer 
with  the  result  that  he  showed  diminished  equilibration.  Balance  was 
lost  with  eyes  closed  at  greatly  reduced  elevations. 

The  operation  report  shows  the  typical  findings  of  a  case  of 
chronic  middle  ear  suppuration  with  cholesteatoma.  The  cholesteatoma 
had  by  its  growth  caused  an  absorption  of  the  bone  of  the  prominence 
of  the  external  semicircular  canal ;  not  an  unusual  finding  in  these 
cases.  Altho  there  was  a  fistula  in  the  osseous  canal,  the  membranous 
canal  had  not  been  affected,  accordingly  Prof.  Alexander  decided  to 
leave  the  labyrinth  alone. 

Surgically  the  wound  did  well,  healing  occurring  completely  after 
a  reasonable  length  of  time  for  such  cases. 

During  the  period  of  after  treatment  we  note  prominently 

(a)  Vertigo*  which  was  quite  pronounced  immediately  follow- 
ing the  operation  and  for  a  day  or  so  afterward.     The  vertigo  then 
grew  gradually  less,  however  it  was  felt  more  or  less  by  the  patient 
when  going  around  even  after  he  had  left  the  hospital. 

This  symptom  taken  together  with  the  next  symptom  to  be  men- 
tioned— spontaneous  nystagmus  to  the  right  (well)  side — tells  us  that 
a  destructive  process  had  occurred  in  the  labyrinth  after  operation 
which  was  probably  of  a  slower  nature  than  a  diffuse  suppuration,  for 
the  patient  retained  hearing  for  at  least  some  weeks  after  the  opera- 
tion. 

(b)  Spontaneous  Rotatory  Nystagmus  to  the  right 
(well)  side  was  present  immediately  following  the  operation  and  di- 
minished gradually  thereafter,  but  had  not  disappeared  entirely  after 
five  months.    At  all  times  the  nystagmus  was  demonstrable,  even  when 
the  patient  looked  straight  ahead. 

The  character,  direction  and  persistency  of  the  nystagmus  found  in 
this  case  is  characteristic  of  any  form  of  destructive  lesion  of  the 
labyrinth  or  more  exactly  of  that  part  which  has  to  do  with  the  static 
and  dynamic  equilibrium. 

(c)  Hearing   was   present   and   demonstrable   with   the   three 
meter  speaking  tube  for  a  considerable  period  after  the  operation,  the 
patient  having  been  able  to  detect  whispered  words  without  failure. 


*The  vertigo  following  the  operation  was  not  due  to  any  fault  of  the  opera- 
tion but  to  the  uncovering  of  an  existing  fistula  which  had  been  sealed  over 
with  a  cholesteatomatous  mass — the  vertigo  was  an  inevitable  sequence. 


222  A  CASE  OF  LAIiyKIXTII  FISTULA. 

Eventually  the  hearing-  grew  less  and  less  until  finally  all  hearing  left 
the  patient,  he  not  being  able  to  recognize  conversational  voice  thru 
the  tube.  Furthermore  he  was  unable  to  hear  the  new,  Edelman- 
Bezold,  small  (a^  fork  that  Professor  Alexander  had  just  acquired 
for  the  clinic.  In  short  the  patient  grew  gradually  deaf  and  the  deaf- 
ness was  absolute. 

(d)  Facial  palsy  developed  late  and  as  all  facial  palsies  do 
which  develop  late  after  the  radical  operation,  it  disappeared  early. 
Complete  recovery  occurring  after  a  few  weeks. 

I  made  several  complete  examinations  of  the  case  for  the  purpose 
of  study,  about  a  month  apart ;  however  to  save  space  I  have  outlined 
but  one  which  was  made  December  loth,  1907.  It  is  shown  above  in 
the  report  and  really  needs  no  further  special  discussion. 

The  patient  had  an  inactive  left  labyrinth,  complete  deafness  and 
demonstrable  equilibrium  disturbance. 


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